51001.3 (2) ILOT NO. r�
No. STREET
y�P�LI�A,�ION FOR PLUMBING PERMIT
z i
d R�� 1OF CUPERTINO
xa Sanitary No.
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° < Uate ��� 19� 6 IF Permit No
3 LL Fee $ 4-0
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h City of Cupertino for a permit to install plumbing
a pipes anc�/or xtur s t 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
a w Cupertino, and all other laws applicable thereto.
w Use of Premises
00
3 Owner z✓-e� Address
�C ✓
� z By � � � � H'°+ Address
O CONTRACTOR, AGENT
3 `m
Phone-a?3 —�77
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s State License 3 �''� Approved �4r'LLIA:JI D. 3C63cVlGH
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U >C11PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water'Heater Size
Water.Closet Material C,
Bath Tub To Curb
Shower l To Prop. Line ✓
Lavatories 3 To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
Waste Dis osal
Wash Trn STORM DRAINAGE
Washin Mechine Sire
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tmy To Curb
Dental Unit j i//V
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Si ie
Restaurant Sink MaterialC.
)
Sand Trap 'TOTAL FEES
Urinal Fixture Fee /9. ,So
Area Drain Main Drain Fee 0i'
Water Leader Storm Drain Fee
S rinkler Valve .,Water SYs.Fee /,
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee ,GG
Total Total FeeJ