51122 (3) LOT NO LT/
NO. STREET
-�1 PA PLIC_ ATf N, FOR UMBING PERMIT
d � � .— � J CITY OP CUPERTINO
x o QR 068 4' Sanitary No.
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o a Date 16 1962 Permit No. S/f.Z 2i
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i401.7< 1-17 !tlOr!?TI?I� Fee ga
o Application is hereby made to the City, of Cupertino for a permit to install plumbing
o � pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
ri- and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
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Use of Premises o./L�l,� rr c ee
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Owner o v �B Ur , Address i0 4 2 .S Tn. [. Lk,)A
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z By f�nITton v^ o/-'�' Addressf92,6-' dM�YIGYf 0 y. �cSe
COrtRACTOR, AGENT
3 PhoneyU
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a o State License /AnX79 Approved WILLIAM C-t
M MNEVI �
—U PLUMBING INSPECTOR ✓
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Si ze
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
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 SinkMaterial
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter /
Permit Fee x 0'11
Total Total Fee t!»