51107.1»>7.i E AA12A iL(2CE
No. Street
g1'Ti7" OF CUPERTINO.
WATER DEPT..
Lot No.
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
Data:�JG 26 119671
Sanitary No.
Permit No. S-11 07, /
12 A Y ® FeeS
Application is hereby made to the City of Cupertino for a permit to install plumbing pipes
and/or fixtures listed on 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 r;& U-14J7G
Owner 610" )
Contractor, Agent
Phone -.?2-2-27/R
State License—22c, 2k2
Address GqL !V r/ G'• 1v/V [!i
Address /�� nnSp'- /^ (Q
Appro edILL1AM r) mCn�r_v.
Plumbing Inspector
FIXTURES NUMBER
MAIN DRAIN
Units Fees
_
Units I Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Pro . Line
Lavatories
To Existing
Kitchen Sink
Dish Washer
Waste Disposal
Wash Tray
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
Water Leade
[),.ipee-
Sprinkler System
Water Sys. Fee
Refief Valve
Gas Fee
Vac Breaker
Skimmer
Filter
J werE
Permit Fee
Total
Total Fee C—r�