51001.3 (2) / 037 1
�- LOT NO.
Nn. STREET
ON FOR PLUMBING PERMIT
CITY OF CUPERTINO
z i
x o / Sanitary No.
NAY
o a ate 2 I4r4 �/ 19KP-4Permit No
3 rF ebPee 5�9.•r4
° Application is h } made to the�City of Cupertino for a permit to install plumbing
o F- pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
r and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
<w Cupertino, and all other laws applicable thereto.
w x
� r
LL Use of Premises .�'e
00 A �� �9�
�l� �L.� � Address y es- - C-a'4c
0 3 Owner
o a /
z By ���y �� / ,Z,r , Address
3 0 ONTRA OR AGENT
— <O
Phone L 7 3— �O 77
w Z
0 I State License 2 o Approved
a o
— PLUMBING INSPECTOR /
r/
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Size
Water Closet Material(e/
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tr—ay 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 .
Area Drain Main Brain Fee
Water Leader Storm Drain Fee
S rinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
ii Permit Fee •�—
Total �, Total Fee