51167.1LOT NO. XIJ/
NO. STREEI'
APPLICATION FOR PLUMBING PERMIT
" < QTY OF CUPERTINO
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xo Rip Sanitary Nu.
0g 196 Permit No s
0 w Date
U ?� JL! A1967 t_ Fee$ S
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� Application is hereby made to the City of Cupertino for a permit to install plumbing
o piges a d/o fixture q_ I the reverse side hereof, and agrees to install said prices
> and-/oi xhlres� in�a da��AOthe provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
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J W Use of Premises// A s
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`o a"/,J Address
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,By //�� �i .✓ Address
O CONTRACTOR, AGENT
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Q0 State License Approved (�•��-----�-<-`�
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- U PLUMBING INSPECTOR
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FIXTURES I NUMBER �� MAIN DRAIN
UNITS FEES UNITS FEES
Water Closet
To Proa. Line
Dish Washer I 1 11 Sewer Box I I I
Bar Sink To Main Drain
Comb.Sink &Tray To Curb
Floor Drain I I I WATER SYSTEM I
AL FEES
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys. Fee /S%J
Total