51107.1aS3' / �•`.� Ws�R 1L/ WLivW LOT
NO. STREET
APPLICATION FOR PLUMBING PERMIT
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Y o �� rCITY�OP CUPERTINO
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.. �l
nitary No.
3 u' Date L v o0I 196P'pe'ti"
ermit No d !• L
�. 03-W
W Fee $
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Appli4ation is hcr�by� ade to the�Gi, of for a permit to install plumbing
o � pipes and fo['fixtu'r'es list 'dl on2Ehe Rk&/side hereof, and agrees to install said prices
> and/or fixtures in accord nce with' Yt'ee provisions of the Plumbing Code of the City of
a w Cupertino, and all other aws Sapp icable thereto.
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j LL Use of Premises V
00 1
0 3 Owner PL11 ..U� A Address
z Byv nu C&Q '1.. Zl-t�[Otc>A Address
TRACEOR, AGENT
-0 u o�lola
m Phonr
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W W WILLIAM D. BENLVia-f
a tUOJ State Licensc��-C Q N 4461) Approved
—Iy PLUMBING INSPECTOR
UNITSI FEES
Boxes
door urams
',WAILK SYSTEM —1
Hoppers
Size
Restaurant Sinks
Material
San raps
TOTAL FEES
Urinals
'Fixture Fee 1-00
re DDrains
Main Drain Fee
Water Leaders
Storm Drain Fee
Sprinkler Valves
Water Sys. Fee -00
Permit Fee
TOTALTOTAL
FEE
RECORD OF INSPECTION
Underground Rough—
Partial Rough -
Rough. Complete -
Main Drain
Final...