51015.2 (3) NO. STREET
APPLICATION-,FOR PLUMBING PERMIT
z � •CITY OF CUPERTINO
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x o D , g 168 Sanitary No.
o a Date 196? Permit No. S,1 `'�S^ �Z'
Pee $
1 0
Application is hereby made 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 fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other la applicable theret,,.
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Use of Premises C
20
3 Owner -��/ Address
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By _ L" /,• Address
0 CONTRACTOR, AGE
3 `m Phone
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(OQ1.'L_L! ^.I D. D::N-V!C',{
y f State License k C/�6 " � Approved
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U PLUMBING INSPECTOR
FIXTURES I NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Tater heater /"4-0 Size N
Water Closet .10 Material G'1
Bath Tub — To Curb
Shower —' To Prop. Line
Lavatories Z 3.r To Existing
Kitchen ink / i,3 C 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 5 SO WATER SYSTEM
Hopper Size
Restaurant Sink /. ,-all Material
Sand Trap 11 TOTAL FEES
Urinal / -0 Fixture Fee 31 ,.SU
Area Drain Main Drain Fee
Water Leader StormDrain Fee
Sprinkler Valve Water Sys.Fee 7>
Relief Valve --t- Gas Fee
Vac Breaker
Skimmer
Filter,
Permit Fee w
Total y /.S c o