51064FIXTURES
NUMBER
MAIN DRAIN
UNITS
FEES
UNITS
FEES
Water Heater
Size
Water Closet
Material
Bath Tub
I To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn.
Dish Washer
Sewer Box
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 Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee
Relief Valve
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total
Total Fee
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NO. STREET
APPLICATION
JITY
C
LOT
FOR PLUMBING PERMIT
OF CUPERTINO
Sanitary No
Date _ 196LT Permit No.
Pit p �`?,4 1 Fee $� 0
rya
Application is`hereby rna'd&16 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
By tit
CONTRACTOR,AGENT
Phone k '%, % 7- '2�r G 7
State License � z 3 Z 90 2r
Address D O
Address 3 a -V ""
Approved (,C/
PLUMBING INSPE<"T�✓