NO PERMIT NUMBER i0( J4 (rr l= .uvlFt , flt;t (�� n�2rrn r
No. Street Lot No.
o —
d APPLICATION FOR PLUMBING PERMIT
E CITY OF CUPERTINO
0
v Sanitary No.
E Date 196 , �,' Permit No.
3 � , � • Fee
Application is hereby made to the City oft Cupertino for,a?permit"=,to install plumbing pipes
and/or fixtures listed on the reverse Sid-L ereot}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. / Trrt r r 1
CU,'tiRTIf�O
A A Use of Premises
o_ U
0 Owner I-[A J L Y Y 0" nl S a1 Address r NV I Fµ
0
c m
a ti By Q w Ai c 2 Address
3 Contractor,Agent
0 Phone - -3 — `3 �{
— -� State License Approved
Plumbing Inspector C/
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen in Not Conn.
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 =FixtumFee
Sand Trap FEES
Urinal Area Drain eWater Leader eeSprinkler System
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee S"�