100,1241 .;246 I kaAld4 &,17 LOT NO.
4RPL=ICATION FOR PLUMBING PERMIT
�:I (i1TY OF CUPERTINO
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Date / — / % 196�7 Permit No 10C),
Fee $
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
Owner ty►
By t3 f L
CONTRACTOR, AGENT
Phone z,? 7— 3 :;->- i
State License-? 7 Z-
i
Address/Vt/c
Address 1571a �+•'� ,Se2'! �i°`�r'-S'
00,
Approved
PLUMBING INSPECTOR
FIXTURES
NU, fBER
MAIN
UNITS
FEES
UNITS
FEES
Water Heate
Size
Water Closets
11 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
Size
Water Softeners
Material
Bar Sinks
To Main Drain
Comb. Sink & Trays
To Curb
Dental Units
Drinking Fountains
Floor Drains
WATER. SYSTEM jkj
Size
Hoppers
Restaurant Sinks
Material
Sand Traps
TOTAL FEES
Urinals
Fixture Fee
Area Drains
Main Drain Fee
Water Leaders
Storm Drain Fee
Sprinkler Valves
Water Sys. Fee
Permit Fee
TOTAL .
TOTAL FEE
RECORD OF INSPECTION
Underground Rough
Partial Rough
-Rough. Complete
:Main Drain
Final