100044 LOT NO.
�D NO.S� �Q Ta OF PLUMBING PERMIT
� < ! OF CUPF.RTINO
IJ L 14
r o 1965Sanitary 1`0.
o a Date L/ 3196x_ Permit No/—Q
3 CITY OF UPERTINO Fees
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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
r and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
a Use of Premises
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3 Ownerd, Jr��^� �4 /of Address-
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z z By W t Address /iW()
— Phone ✓�-`' / �� �li^1,ti-ce—`,!J
a o State License ' Approved
-V. / CONTRACTOR, AGENT
FIXTURES NUIN BER MAINDRAIN
UNITS FEES UNITS FEES,
Water Beater Size 3',
Water .losets Matcda'_ C',£
Bath jiubs 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
'.dater Softeners Material
Bar Sinks To Main Drain
Comb. Sink : Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
San Traps TOTAL FEES
Urinals Fixture Fee
Area Drains Main Drain Fee
iEster Leaders Storm Drain Fee
Sprinller Valves Water Sys. Fee
Permit Fee j
TOTAL TOTAL FEE :
RECORD OF INSPECTION
Underground Rough...
.Partial Rough..
.Rough. Complete..
.Dain Drain
Final...