100111 % LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
W 6 ^CITY OF CUPERTINO
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oll.c ai Sanitary No.
tt g 196.E 60
Permit No / .
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3 u ( � 'r'u 001 Pee $—,�
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� A lication is hereby, made to the City, of Cupertino for a permit to install plumbing
o r p �s . dfixtfl�c521TIn1fd1 reverse side hereof, and agrees to install said prices
> a an /or fixtures In acro an c i l the provisions of the Plumbing Code of the City of
a w Cupertino, and ill laws applicable thereto.
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Use of Premise
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O C 7RACT AGENT
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u fV State License —� Approved
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PLUMBING INSPECTOR
FIXTURESANUMBER MAIN DRAIN
UNrrS FEES
Water heaterSize
Water Closet Material
Bath TubTo Curb
Shower1'o PrLavatoriesTo Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
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
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader I Storm Drain Fee
Sprinkler Valve Water $ s.Fee ,
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
I
Permit Fee
Total Q�O I Total Fee