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SLOT NO.
VAN
hoNAPPLICATj (R1FOR PLUMBING PERMIT
m a 17 X965 .Y OF CUPERTINO
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x o Sanitary No.
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o Ur[trTs 1966 Permit No
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o Application is hereby made to the City of Cupertino for a permit to install plumbing
`o a 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
a Cupertino, and all other laws applicable thereto.
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r 3 Owner 54 L-Ck — Address 6 311 e �
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By 1Y6,11 , l/•s7`�� naare55o
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3 CONTRACTOR, AGENT J 62A-3Z�
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Approved. /
-U PLUMBING INSPECTOR
1
FIX I URESNUMBER
UNITS FEES UNITS FEES
Water Hrate 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 Size
Water Softeners Material
Bar Sinks To Main Drain
Com . Sinks Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
San Traps TOTAL FEES
Urinals Fixture Fee Cho
Area Drains Main Drain Fee
eater Leaders Storm Drain Fee
Jprinklcr Volvcs Water Sys. Fee
Permit Fee o2
TOTAL TOTAL FEE ov
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
'Iain Drain
Final .