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NO. STREET
APPCIC . TIO`M FORPLUMBING PERMIT
'(TPY [11,I,UPERTINO
OV 6 1967 J Sanitary No.
Date 1967 Permit No .S7/6 7. z
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Application is�fiere�by made! til City q, 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.
of Premises
CONTRACTOR, AGENT
Phone S ;''�' J
State License 1� ��
Address
Address
PLUMBING INSPECTOR (
FIXTURES NUMBER —MAIN DRAIN
UNITS FEES__ UNI'CS F
1T7—
Closet
To PrOO. Line
Dish Washer I 1 11 Sewer Box I I I
STORM
Comb.Sink&Tray I 1 11 To Curb
Urmkm Pountmn
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 Valve
- Water Sys. Fee 15- J
Relief Valve
Cas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total
11 Total Fee .7GS7J