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NO. STREET
P1,
� N FOR PLUMBING PERMIT
TY OP CUPERTINO
° CT 1 9 Sanitary \'u.
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° a Date �J 196 G s^ Permit No. _4—/0 ,2 7 7
3UFee
° CITYpliiQlc n / DMN
O the City- of Cupertino for a permit to install bing
o W pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
a and/or fixtures in accordance with the provisions of the Plumbing Code of the Cay of
a w Cupertino, and all other laws applicable thereto.
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j Use of Premises .o N �i
o o �o e g o -Ij To c,4e Xo y,
3 Owner—C-2119 Y l /Q/SS mir/l/ Address C- Li,0,Ag?...-M
z By Address
05�Pc�S / 9 G G
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O CONTRACTOR, AGENT
— m Phone
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ao State Licence 0 s 7 y 8 Approved
—0 TPLUMBING INSPECTOR
1� �
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heate Size
Water Closets Material
Bath Tubs To Cur
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks p Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
rill Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Com . Sink s Trays To Curb
Dental Units
Drinking Fountains
F' oor Drains WATER SYSTEM
uppers Size
RestaurantSinks Material
an raps 11TOTAL FEES
ring Is Fixture Feel5 O
rea rains Main Drain Fee
eater Leaders Storm Drain Fee
�prinkkr Valvcs Water Sys. Fee
@ Permit Fee
TOTAL TOTAL FEE 8 ��
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final