51192 (2)1 A hL r Cf. LOT NO. /
NO. STREET
r P CATION FOR PLUMBING PERMIT
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UPF.RTINO
ro Sanitary No.
o f 1� 3 196 Permit No -1,-// y t�
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wLL Fee $ c;2
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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
>r and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
< w Cupertino, and all other laws applicable thereto.
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Use of Premises /&S
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r 3 Owner
_A'4 i+ %%x,65 Address
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° 62TP0psrles res iNT
— 0 Phone tan lose. California 95112
aa State License Approved
- U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
WE UNITS I FEES 11 UNITS I FEES
Closet
To Prop. Line
es
Sewer
STORM
Machine
Comb.Sink&Tray I 1 11 To Curb /i
Floor Drain WATER SYSTEM
Hopper Size /�� I/ 1
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 a
Total
10 5 Total Fee Q(j