51015.2 (3) No. Street Lot No.
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N
E PLICATION FOR PLUMBING PERMIT
:j CITY OF CUPERTINO
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'0 C 29 1970 Sanitary No.
E Date/ 6 O , IWL/ Permit NN`%o /J-7-Z
3 CITY OF CUPERTINO Feed°=
v Application is hereby made to the City of Cupertino for a permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof, and agrees to install said prices and/or fixtures
° in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
"e laws applicable thereto.
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Use of Premises )
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Owner � �/ Address
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e y By � �„ Address
3 / Contractor,Agent
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d ° Phone
State License Approved
Plumbing Inspector
at /021.90 ;
FIXTURES NUMBER MAIN DRAIN a
Units Fees Units Fees
Water Heater Size
Water Closet Material C '7—
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Exi tin
Kitchen Sink Not Conn.
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.S ink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL'FE 93
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief Valve I Gaq Fee,
Vac Breaker
Skimmer
Filter
Permit Fee oZ
Total `= Total Fee