51043.1 (6) Civ ` �� • LOT NO.
N 11/ APPL AT'10 \FOR PLUMBING PERMIT
< C T
zOP CUPFRTINO
i
MAY
I
x g — 5 1966 ' sanitary No.
2 4 Siu�3%
o a Data-�"- 6 196 Permit No
3 U * OFCUPERTINO Fee $ 71
1 0
° Application is hereby made to the City of Cupertino for a permit to install plumbing
o 1 pipes and/or fixtures listed on the reverse side hereof, and agrees to install said rims
> and/or fixtures in accordance with the provisions of the Plumbing Code of the Cityg of
a w Cupertino, and all other laws applicable thereto. �B4
w � 0
0 LL Use of Premises
00
3 Owner /lj�1f✓ 121uoe I o, Address,239'5-/&16-
oz By. �.�/nC %1rF A-�SOJ _Ny!' Address
3 CONTR9C70R, AGENT
- m Phone �,�lD- MV
w z
a �sia�
State LicenseApproved
U40orPLUMBING INSPECTOR
�oL
FIX I URES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heate /� Size el
Water Closets Material (µ5T
Bath Tubs y To Cur
Showers (p To Prop. Line
Lavatories 8 To Existing ✓
Kitchen SinNot Conn.
Dis Washers Sewer Boxes
Waste Disposa
asli Trays STORM DRAINAGE
Washing Machines Size
Nater Softeners Material
Bar Sinks To Main Drain
Comb—Sink s Trays To Curb
Dental Units
Drin ing Fountains
I' oor Drains WATER SYSTEM
Hoppers ize
Restaurant Sinks Material G
San raps TOTAL FEES
Unna s Fixture Fee a-p
rea rains Main Drain Fee
-t ater Leaders Storm Drain Fee
Sprinkler Volves Water Sys. Fee /10-0
Permit Fee �,µq
TOTAL TOTAL FEE ,
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final