100268 22�L-/ I STc c•c.US C2C��{! �Q LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
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x o DEC10 �9_4Sanitary No.
RLL FJ � � 19 � Permit No /oo
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' 0 Application ishereby made to the City of Cupertino for a permit to install plumbing
o a 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 m Cupertino, and all other laws applicable thereto.
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a Use of Premises
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3 Owner D 4 Gf-f/-I/-/ � , l Address ,-4e�
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o By /fed PL6C- .SERVICE / �^•4-•�� cldress396 /6-A2Y176�
3 F CONTRACTOR, AGENT
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0 2 State License '� 7 -7 Approved
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PLUMBING INSPECTOR
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FIXTURES NUMBER MAIN DRAIN
Units Fees U 'ts Fees
Water Heater ' !.cr Size
Water Closet Material
Bath Tub 11 To Curb
Shower To Pro . Line
Lavatories To Existing
Kitchen 'n 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 -
jni[Fountainrain WATER SYSTEM
Size
nt Sink Material
TOTAL FEES
Fixture Fee .j 0
in Main Drain Fee
eader Storm Drain Fee
Sprinkler System Water Sys.Fee
Relief Vnlye 11 G2q Fee,
Vac Breaker
Skimmer
Filter
Pool Sweeper
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Permit Fee --271 do
Total To[al Fee . 3, s53