51001.4 GV�V LOT xn.
NO. ""T
,-APPLICATION�i-FOR`PLUMBING PERMIT
CITY O ('UPERTINO
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' (Z0 I `\ 1 [JUL r:� 1.cJ6a .. Sanitary No.
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o a Date d 3 19Ciff- Permit No
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w LL f+•'.\ i �� Pee $ ;.
o 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
I and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
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a Use of Premises
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7 N
0 3 Owner Address
z By O�/t-ice (!� .��c�.- Address Aif +
O CONTRACTOR, AGENT
� Phone 2-5 4`0 77
L< o State License a 3 93.1 Approved
PLUMBING INSPECTOR
X1
FIXTURES NUMBER MAIN DRAIN
UNITS FEES 11 1 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 K Sewer Box
Waste Dis os
Wnsh Tr STORM DRAINAGE
Washin Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tm To Curb
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trapl' l'AL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee 6 .CYO
Water Leader Stone Drain Fee
Sprinkler Valve Water Sys.Fee /.
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee o� _