51231.1 / _No.D St eet Lot No.
CITY OF CUPERTINO
y WATER DEPT.
APPLICATION FOR PLUMBING PERMIT
O
AUG 9 1971 CITY OF CUPERTINO
Sanitary No.
P. A 1r71
EDate , 19 Permit No. `S
3 Fee Sr.22
v Application is hereby made to the City of Cupertino for a permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof, and agrees to install said prices and/or fixtures
in accordance with the provisions of[h Plumbing Code of the City of Cupertino,and all other
laws applicable thereto.
0
n n Use o(Premis
o_ :J
Owner Address
c m
By Address
3 Contrac r,Agent
o Phone
� 3
State License � 7�0 Approved
Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units I Fees
Water Heater Size
Water Closet Material
Bath Tub I To Curb
Shower To ProD.Line (/
Lavatories To Existing
Kitchen Not Conn.
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material .7
Sand Trap TOTAL FEES
Urinal Fixture Fee 6 ��
Area Drain Main Drain Fee ")
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee d
Relief Valve G2q Fee f
J
Vac Breaker
Skimmer
Filter
Permit Fee . JJ
Total Total Fee