51046 /y G lL —/ I �ITL.t.�[ i K^DZ� A(_ LOT NO,
NO. STREET
APPLICAT QN FOR PLUMBING PERMIT
z J9' C ITYJ QF_; CUPERTINO
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zo Sanitary No.
0 < Date t' /C EP 196— Permit No -,C—/ G `f-6
I Fee S 71
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n w Applic£tionVs h'cr�y 'l¢ 99tDLthcjCityjof Cupertino for a permit to Install plumbing
0 a pipes andJor' f�xtu�es la�dd bnLthelreverse 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 w Cupertino, and all other laws applicable thereto.
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W Use of Premises
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3 Owner�F��✓�� C!/ Address
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o By ����+�'' �k' Address/A10o
CONTRACTOR, AGENT
a Phone
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u Y State License Approved
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{�—U PLUMBING INSPECTOR v
FIXTURES I NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater 11 Size
Water Closet Material
Bath Tub 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 j--11
Water Leader Storm Drain Fee
S rinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee °
Total 'Dotal Fee ' a I