51043.1 (21) �O OD I LOT N
NO. 5
, AQP TION FOR PLUMBING PERMIT
z do Y OF CUPERTINO
x o ® Sanitary No.
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01 DAt 1962 Permit No
3U
w a Pee S
° �� a City of Cupertino for a permit to install plumbing
`o pesland/�I' fixt49i�#' 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
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Cupertino, and all othe�s applicable thereto.
4 Use of Premises
00
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r 3 Owner LE `J „f) Address
0 By CONTRACTOR, AGENT 625 JIC`55
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PhoneSan os San Jose, California 95112
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0 a State License.��/�3� Approved
—U � PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UN S FEES UNITS FEES
Water Heater size
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
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size 11
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixtare Fee /00 S'0
Area Drain Main Drain Fee
Water Leader Stom Drain Fee
Sprinkler Valve Water s.Fee 6�
Relief Valve Gas Fee 6�
Vac Breaker
Skimmer
Filter
Permit Fee
Total XV -0 Total Fee Q,5