51231.1 00 ' ®A102_
No. Street Lot No.
.N UITY OF CUPERTIN .
WATER DEPFj APPLICATION FOR PLUMBING PERMIT
E �U G 9 1971 CITY OF CUPERTINO
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Sanitary No.
Permit No.
3 Fee S.-2 t< S a
s 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 the Plumbing Code of the City of Cupertino,and all other
1.2 laws applicable thereto.
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v
=, b Use of Premis
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° Owner Address
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By 'O Address ,
3 �C/oJ�tracto ,Agent
° Phone ; /'/ L/'Ga
ro 3 /! 4 f7 n
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St�[e License Approved
L rJ�--p�j� Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater I Size
Water Closet Material
Bath Tub f To Curb
Shower f To ProD. Line
Lavatories To Existing
Kitchen Sink 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 i
5 ¢
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee G7,al
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee I S
Refief Valve 11 C.2s Fee,
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Vac Breaker
Skimmer
Filter
Permit Fee _ UJ
Total S Total Fee