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VSEPATPLjq$t I I FOR PLUMBING '?ERMIT
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OF CUPI:RT[NO
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' X I Sanitary No
o a DatV1Ti%Fc?dPERTIN.0quS Permit Nr-10-V, o
4 Pee $
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� Application is hereby made to the City of Cupertino for a permit to install plumbing
01 pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
> I and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other I g applicable thereto.tt—hereto.
0 o Use of Premises
> � SIj BOO/tom�!�
3 OwnerG' Address +-�- �
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By / 5 Ua-AXAddress
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CONTRACTgR AGENT V
w i Phone --Z- �'R 0
co State License (J�t r i C7 ApprovedLl/ �6.2���
0 I� PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
IShowers;
Hcatc Size
ClosesMaterial
ubs To Curb To Prop. Line
ries To Existing
n Sinks Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks q To Main Drain
Com . Sink-& Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
San Traps TOTAL FEES
Urinals Fixture Fee O's
yArea Brains Main Drain Fee
\Y/ater Leaders Storm Drain Fee
Sprmkler,Val,es Water Sys. Fee /
Permit Fee
TOTAL I TOTAL FEE
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
\•Iain Drain
Final