100227 2� Sys STf /!n/S Creek' L31cl
c No. Street Lot No.
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y
APPLICATION FOR PLUMBING PERMIT
c � CITY OF CUPERTINO
N �'A � Sanitary No.
E s� Date_C _!Q�\ , 196_ Permit No/ 0 0 .ZZ
3 `S Gw Pee S
v Applicati�ofis hereby made to the City of Cupertino for a permit to install plumbing pipes
a andj,oi fixtures listed on the reverse side hereof,and agrees to install said prices and/or fixtures
,i Ivlaccordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
"c laws applicable thereto.
m ro Use of Premises
p U _
° Owner Address
o i
e
Address4yL Gt/
3 E Contractor,Agent
Phoney--
State Licens(C +Z Approved
Plum mg Inspector �
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Pro .Line
Lavatories To Existing
Kitchenin n.
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
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee