51167.1 (2)W3
LOT NO. -A
¢1PPLIC-A31 IT FOR PLUMBING
—`�j,� IT1OP CUPF.RTINO
Date 1967pil
l967
PERMIT
Sanitary No.
Permit No. S—"/(r 7,/
Pee $ -,2- C- S -a
A ilic3liod)s hefcbX + aQ2�,`t' �tMCity of Cupertino for a permit to install plumbing
pipes and%or Yfiztures'7isted on f�VYeverse 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 Premises
,
Owne/
Address_
ByY/��ilx 1L/�li0�iz<i
Address
CONTRACTOR, AGENT
State License. xjI ; 5-7%
Approved_
PLUMBING INSPECTOR
FIXTURES NUMBER
UNITS FEES
Water Heater
Water Closet
Bath Tub /
Shower /
Lavatories
Kitchen Sink /
Dish Washer
Waste Disposal
Wash Tray
Washing Machine
Water Softener
Bar Sink
Comb.Sink & Tray
Dental Unit
Drinking Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler Valve
Relief Valve
Vac Breaker
Skimmer
Filter
Total 0a
MAIN DRAIN
UNITS FEES
Size
Material /
To Curb
T Prop. Line ✓
To Existing
Not Conn.
Sewer Box
STORM DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size
Material
TOTAL FEES
Fixture Fee
Main Drain Fee i
Storm Drain Fee
Water Sys. Fee i
Cas Fee
Permit Fee
Total Fee