51167.1LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
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TN
OF CUPLRTINO
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x o Sanitary No.
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o Date `7 1 Permit No .S //6 7 /
w LL Pee $ 07,3 S�
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= w APplieation�,sare�e,5}I*�r._ e•SSolthe�City of Cupertino for a permit to install plumbing
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nilXor xtures4atedNilthe. reverse side hereof, and agrees to install said prices
> ra- and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
< w Cupertino, and all other laws applicable thereto.
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a Use .pf Premises
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0 Address
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O 'CONTRACTOR, AGENy
W Phone-�-�
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p WILLAAi C. Eiz;JEVICH
ao Approved Li/
U PLUMBING INSPECTOR
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FIXTURES
NUMBER
MAIN DRAIN
UNITS FEES
UNITS FEES
Water heater
f
Size
Water Closet
Material
Bath Tub
/
To Curb
Shower
/
To Prop. Line
Lavatories
.2
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
Water Leader
Stone Drain Fee
Sprinkler Valve
Water S s. Fee
Relief Valve
Gas Fee /5
Vac Breaker
'
Skimmer
Filter
Permit Fee <B�
Total
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Total Fee j,