51075.5 (5) No. Street Lot No.
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d APPLICA O 1 R T
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Y Date ,CITY
h9T`/ Permit No. S�°
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r Application is hereby made to the City of Cu �jCh1SW to install plumbing
and/or fixtures listed on the reverse side hereof,and agrees to install said prices and/or fixtures
0 in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
'E laws applicable the to. _ I
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n Use of Premises
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° Owner7rac
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3 'AAennt
Phone
WILLIAM D. D--iV.:VIC1
State License _ Approved
Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees U '[s Fees
Water Heater Size
Water Closet / Material
Bath Tub To Curb
Shower To Prop.Line
Lavatories zo To Existing
Kitchen n
Dish Washer
Waste Disposal
Wash TraySTORM 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
Ho er Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal I Fixture Fee
Area Drain 1 Main Drain Fee d 0-0
Water Leader 1 Storm Drain Fee
Sprinkler System 11 Water Sys. Fee
Relief ValverGaq Fee
Vac Breaker
Skimmer
Filter
Perntit Fee
Total Total Fee