NO PERMIT NUMBER c No. Street Lot No.
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v APPLICATION FOR PLUMBING PERMIT
E CITY OF CUPERTINO
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ySanitary No.
� Permit No.
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Date ia
� I N OV 12 196 I`
3 Fee$ G S�
m Application is hereby made to the City of Cupertino for a permit to install plumbing pipes
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and/or fixturesrlis[ed,ontt're.revetrrse side,hT ofl and agrees to install said prices and/or fixtures
-- --0-,.. ---in-accordance wiihl the provisions Vfjttie.t umbmg Code.ofthe.City_of Cupertino,_and.all.other_
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5 laws applicable thereto.
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A A Use or Premises
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o Owner ��GZ� Address 0
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a N By Address/1
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3 � ontracto ,Agent
Phone
-a State License i'�T d X �_ Approved
Plumbing Inspector
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FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Showery' To Pro . Lin
Lavatories To Existing
Kitchen ink 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 I WATER SYSTLI4 A,
Hopper I Size
Restaurant Sink Material
Sand Trap TOTA FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief Valye 11 Ga�Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee