51075.5/D/o/ I �D F iavLOT NO.
NO. STREET
A ON FOR PLUMBING PERMIT
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wITY OF CUPERTINO
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19L'� Permit No AM/2) 21ri
a `�pee $ .
oher �1e to the City of Cupertino for a permit to install plumbing
o pipes and/or fVu [� to on the reverse side hereof, and agrees to install said prices
> and/or urf'fjn accordance with the provisions of the Plumbing Code of the City of
¢ Cope fI an all other laws pplicable thereto.
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PLUMBING INSPECTOR ✓
FIXTURES NUMBER
Units Fees
Water Heater
Water Closet
Bath Tub
Shower
Lav t r'
Dish Washer
Waste Disposal
Wash Tray
WashingMachine
Water Softener
Bar Sink
Comb.Smk & Tra
Dental Unit
Drinkin Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler System
Relief Valve
Vac Breaker
Skimmer
Filter
Pool Sweeper
Total
MAIN DRAIN
Units Fees
Size
Material C'
To Curb
To Prop.
Line
To Existing
Not Conn.
STORM DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size ri
Material
1—
TOTAL FEES
Fixture Fee
Main Drain Fee
form Drain Fee
Water Sys. Fee
Permit Fee
Total Fee