51075.5 (3) No. Street Lot No.
o —
a APPTIO�LQR PLUMBING PERMIT
B 17'YtQFCUPERTINO
o
h
ni[ary No.
��c _
ro
E Date , 19627 196,8 Permit No. S i c 7J,J
0 / L
° Y Fee$
3
Application is hereby made to the Qlo(rupertino for a permit to install plumbing pipes
and/or futures listed on the reverse si `ff`oI))inagrees to install said prices and/or fixtures
° ,; in accordance with the provisions of the Plumbs Qdh of the City of Cupertino,and all other
'E laws applicable thereto. V
d �
m -a Use of Premises U
o ` / V
° Owner ��[.-C�e.o �"'�-/ Address
By /� 02.1 / dT-�✓/
3 3 C ractor,Agent E �,
° Phone 3 •3 74 $4
/�- State LicenseC / (C / Z �. ApprovedVVILLIP-11
Plumbing Inspector��
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
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
Restaurent Sink Uea
Sand Trap ES
Urinal Are Drain W der Sprinkler System
Relief Vnlye I Gas Fee
Vac Breaker
Sk mmer
Filter
Permit Fee
Total Total Fee