1784 LOT NO.
NO. STREET
�4 TION FOR PLUMBING PERMIT
?te�—
ITY OF CUPERTINO
EP6 1962 0 ` , 195_ Permit No. �o /
CITY OF Cyffi I10 Fee $
Application Is here y ma. e 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.
Pse of Premises
Owner Address 6f/ f70�n eaq
By Address ss ati
J/-_IP7Y NTRACTOR, AGENT � •1
ING INSPEF' Approve
PLUMBOR
FIX URES-7 NUMBER MAIN DRAIN
UNITS I FEES UNITS FEES
Water Heater IUb � Size
Water Closets � Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn.
Dish Washers SEWER BOXES
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines ?Le) 9�1 Size
Water Softeners / � y d0�� Material � I
Bar Sinks To Main Drain
Comb: Sink s.TraysTo Curb
Dental Units /
Drinking Fountains) II _
Floor Drains (/p WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
Sand Traps TOTAL FEES
Urinals Fixture Fee !rU
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
Sprinkler Vaives I I Water Sys. Fee �/Z)
Permit Fee
TOTAL �� TOTAL FEE Vu
RECORD OF INSPECTION
Partial Rough
Rough Complete
Final