51001.3 LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
< CITY OF CUPERTINO
w Z ® �1
r o Sanitary No.
o f Dat 1 196 Permit No
w U - 19 1967 �.� Fee $ ,2X--
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� Applications is hereby made to the City of Cupertino for a permit to install plumbing
o pipes'*'and%or7lfistu[es!! �fjau1�re reverse side hereof, and agrees to install said prices
> < and/or fixtutes in IatE� Sn�c��11 'jhe provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
4 Use of Premises
Address
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, By �� Address �� GLp�
O CONTRACTOR, AGENT
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— Phone'=�9'&—cP�O 7 7
ww �rn_r r.nq r -••r.l•1r•••
0 f State License a3 oc'%3s— Approved
f_a o /
Q V PLUMBING INSPECTOR V
X
FIXTURES NUMBER MAIN DRAIN
UNITS 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
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee 11-00
Area Drain Main Drain Fee •QO
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee 06 to
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee O
Total Total Fee I ��