51192 (2)�U
j9967 1 r;,Lirs fft <:2: LOT NO.
NO. STRT.r.T
APPLICATION
���/� clTv
11 1b . 1961
FOR PLUMBING PERMIT
OF CUPERTINO
Sanitary No.
Permit No
fee$
Application is 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 in accordance with the provisions of the Plumbing Code of the City of
Cupertino, and all other laws applicable thereto.
Use of Premises
Ownertkt-A�- �40/LS Address
By C2MtA6l SR""CQ Co" 9� Address
62MTR1tfSTSWENT
Phone tnSg ralifnrnia 95112
State License 17/5'37
PLUMBING INSPECTOR
W&FIXTUHES
NUMBER
MAIN DRAIN
UNITS I FEES
UNITS FEES
Water Heater
1
Size t4 "
Water Closet
J.00
Material
Bath Tub
To Curb
Shower
/
To Prop. Line
Lavatories
To Existing
Kitchen 5ink
I Not Conn.
Dish Washer
Sewer Box
Waste Disposal
Wash Tray
STORM DRAINAGE
Washing Machine
.$U
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinkin Fountain
Floor Drain
WATER SYSTEM
Hopper
Size /"
Restaurant Sink
Material G
Sand Trap
TOTAL FEES
Urinal
Fixture Fee /,- don
Area Drain
I Main Drain Fee p
Water Leader
Stonn Drain Fee
Sprinkler Valve
Water Sys. Fee ,
Relief Valve
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee CA A0
Total
/p /$
Total Fee