51167No. Street Lot No.
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APPLICATION RSP GIMIT
o CIT OV6JELIMOI 1
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San tj tary. No_ 's
S/l6 7
E Date ✓ G� 2 'z— 196&- 5 Permit No.
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Pee $ /�, D O
° Application is hereby made t0fli City of C pertino.fforta permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof, and agrees to install said prices and/or fixtures
0 in accordance with the provisions of the Plumbing Code of the City of Cupertino, and all other
laws applicable thereto. e
A Use of Premises
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° Owner .L. / 5 19 /i Address
--G BY f G 7'7. t �.>-5 /f Address_
3 Contractor, Agent
-`d 2%- 27e3 ° Phone �
— State License Z 2 y 'L Approv j
Plumbing Inspector
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units
Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
i t'
Kitchen Sink
Not Conn.
Dish Washer
Waste Disposal
WashTray
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinking Fountain
Floor Drain
WATER SYSTEM
Hopper
Size
Restaurant Sink
Material
Sand Trap
TOTAL FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
• S --a
Water Leaderto
Sprinkler System
Water Sys. Fee
Refief Valve,
G2.q Fee
S
Vac Breaker
Skimmer
Filter
Permit Fee ca.
Total3
7.33 11
Total Fee /
0 0