NO PERMIT NUMBER (2) LOT NO. 4/
NO. STREET
APPLICATION FOR PLUMBING PERMIT
z < CITY OF CUPERTINO
z -S S
r ° r A— __, Sanitary No. /
n �
0 j Date 196'' Permit No
w� 5 " SEP 25 1967 reel L3 s—o
2 LL
° Application is hereby made to the City of Cupertino for a permit to install plumbing
`o pipes aqdJor fixtures li led n•the. reverse side hereof, and agrees to install said priceS
> and/orBxtures inliccordancykwitA the.provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
LL Use of Premises -
0 0 x.79 y
1 N /� y
3 Owner Address
Address
° CTRACEOR, AGENT
0
— Phone
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¢ a /SGS
0 f State License �� Approvedr c- t t
1 a o
1d
—0 PLUMBING INSPECTOR V/
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Size
Water Closet o2- Material G/
Bath Tub / To Curb
Shower / To Prop. Line
Lavatories To Existing
Kitchen Sink / Not Conn,
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washin Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tmy To Curb
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee Lf
Area Drain Main Drain Fee IS—fy
Water Leader Storm Drain Fee
S rink)er Val ve Water Sys.Fee ry
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee B�
Total fe Total Fee