51167.1— U�Jt
LOT
NO, 5T EF. "r
�A_PMTION FOR PLUMBING PERMIT
ea lTY OF CUPERTINO q
fps "I Sanitary No.
D. C', 1962 Permit No
Fee $ z 4 SZ
p�j�j�ca (( is the City of Cupertino for a permit to install plumbing
i s+and�� fixBdNldB�'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
Cupertino, and all other laws applicable thereto.
Use of Premises
ne
By-
' /CO�. RACTOR, AGENT
Phone — a `gam ``gam ` 7
Address
State License Approved
/J1
PLUMBING INSPECTOR
FIXTURES NUMBER
UNITS FEES
Watcr Heater
Water Closet
B4ch Tab
Shower
Lavatories
Kitchen Sink
Dish Washer
Waste Disposal
Wash Tray
Washing Machine
Water Softener
Bar Sink
Comb.Sink & Tra
Dental Unit
Drinkin Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler Valve
Relief Valve
Vac Breaker
Skimmer
Filter
Total
MAIN DRAIN
UNITS FEES
Size
Material /
To Curb
To Prop. Line ✓
To Existing
Not Conn.
Sewer Box
STORM DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size
Material
TOTAL FEES
Fixture Fee
Main Drain Fee
$tom Drain Fee
Water Sys. Fee
Gas Fee
Pemtit Fee
Total Fee A2a5-V