51187.1No. Street Lot No.
CITY OF CUPERTINO
WATER DEPT.
3 1971
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
Dater & n 93 , 196_
Sanitary No.
Permit Nj // 17. /
Fee S_LLo
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
laws applicable thereto.
Use of
Owner
By Address
Contractor, Agent
Phone
State Licensees Approv d
Plumbing Inspector
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prov: Line
Lavatories
To Existin
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
Relief ValycI1i
Gas Fee A.—V
Vac Breaker
Skimmer
Filter
OP
I
Permit Fee p2 cr-
Totalf
7,S 9
Total Fee