51015.1 2�Sao I STL�V�US C.KLG� LOT NO.
NO. STREET'
CITY OF CUPERTINO
W APPLICATION FOR 'PLUMBING PERMIT
x o mnitary No.
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3 a Date 1� es7w*[uveanyp 191 Permit No
0 Fee $SIp=
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_ ApplicuioOV1
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1 to the City of Cupertino for a permit to install plumbing
o : pipes and/or fixtures listed on the reverse side hereof. and agrees to install said prices
> and/or Gstur� ig&cnJrd c with the provisions of the Plumbing Code of the City of
a w Cupertino, and all otlicr j"a"ws applicable thereto.
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LL Use of Premises
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3 Owner kk,;& Address
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F CONTRACTOR, AGENT
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— 0 Phone 377
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ao State License 210 - Z`�� Approved
_U PLUMBING INSPECTOR ��
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater / Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. 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
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Re]ief Valve Gas Fee /. Z--t)
Vac Breaker
Skimmer
Filter
Pool Sweeper
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Permit Fee a'
Total Total Fee !—�