51075.3 (9) No. Street Lot No.
A /o qoa �n�rgc(
d p APPLICATION FOR PLUMBING PERMIT
E �� CITY OF CUPERTINO
0
Sanitary No.
E pqll� //CIPGY?k� f� , 19i7L Permit No4 /0 73;3
0 `Q QQ Fee$014a
r Application R hereby made to the City of Cupertino for a permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof,and agrees to install said prices and/or fixtures
o in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
laws applicable thereto.
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y w
m UUse of Premises M a T7 c'/�G.
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o Owner Address 1690J)%4w rAa l
c � CA RSoM pNrMRO G/MBCLL
BY /Y/iO�w f3G Jam. /� Address l_5 21
3 ,$ Contractor,Agent
3 Phone e2`f o2—�715�O
� p 3-17-71 ,- .�c,/FrQ/n.�
State License /�'�R13 Approved
Plumbing Inspector V
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories T Exi tin
Kitcluin
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
Sprinkler System I Water Sys. Fee
Vac Breaker N -
Skimmer
Filter
Permit Fee
Total Total Fee