NO PERMIT NUMBER (3) aL
❑ No. Street Lot No. /
o —
d APPLIVOIDT
IT
0
U
1.J. 1969anit o.
Y Date �U 9 19 O�y
Permit No.
o Fee SJ2,S0
3 C�T�. �� �RAT�M
Application is hereby made tote rty o Cue i i[ to install plumbing pipes
and/or fixtures listed on the reverse side hereof,and agrees to install said prices and/or fixtures
o in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
-� laws applicable thereto.
0
A A Use of Premises
o U
oOwner Address
��l aO ,,G" 9 Po 12-
a h By �e Address
3 Contractor,Agent �'7G rlK� wiv e_
o Phone 4r— 7Z O d
A AILLWA D. 3ZNEVICH
State License 2� T �.�S ApprovedN ✓
�1 _ Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material Afr
Bath Tub To Curb
Shower To Prop. Line r
Lavatories To Existing
Kit hen in 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 /h"
Restaurant Sink Material Ora,v
Sand Trap TOTAL FEES
Urinal Fixture Fee S—,o
Area Drain Main Drain Fee .s O O
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee /. 5--a
Refief Valve Gaq Fee 1-0
Vac Breaker
Skimmer
Filter
Permit Fee oZ• &-5
Total W7z!1" Total Fee 3. ,1"v