51130 (3) /0/0. / 'A,� 7I LOT NO.
No g S F.
® N FOR PLUMBING PERMIT
TY OF CUPERTINO
,APR 15 196
x p Sanitary No.
o J Date / 196— Permit No
3) CIT Fee $ rte
x o
� Application is hereby made to the City of Cupertino for a permit to install plumbing
a a pipes and/or fixtures listed on the 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 x (iC�CGGL
0 LL Use of Premises
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0 3 Owne6,C/ ��,� Addres /�
o z Bv,� ''� Address/�Z!! �� �4.e"./'
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CONTRACTOR, AGENT
3 t'L-,K- �s�z
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Phone
W Z
Q a /7 7 3e o Approved
a o State License
—0 PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRX!K'
UNITS FEES UNITSI FEES
W
ater size
ets Material
To Curb
To Prop. Line
To Existing
ks Not Conn.
Dish Washers I Sewer Boxes
Waste Disposals
aST Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Com . Sin s rays .To Curb
Dental Units
Dunking Fountains
Floor Drains WATER SYSTEM
Hoppers Size "
Restaurant Sinks Material
San raps TOTAL FEES
Unna s Fixture Fee 3
7715rains Main Drain Fee
Water Leaders Storm Drain Fee
Tprinl:lrr Valves Water Sys. Fee / ,tsL
Permit Fee
TOTAL TOTAL FEE
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final