51167.1 (2)(�,(.Cll�J79/G.!/ [ -C1 LOT NO.
NO. STREET
SAPPLICA---���TION FOR PLUMBING PERMIT
w a / -, �' 1•TY OF CUPF.RTINO
s C
o Sanitary No.
� r 1-'':-1,96Z
} SYo a Uate� -� q6Permit No s//67a
34 Pee$
�o
� Applieationli; herefzy7nadrltotthe City of Cupertino for a permit to install plumbing
o pipes ;and/or-fi'xture�fti�tcrdVon Itl c.Jreverse 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.
Use of Premises/�l�xa' -�> ✓ -�
r 3 Owner /il.Y2'l- /� Address
o <
z Bya,��`w� Y".��% ��G�// Address
—C�NTAACIOA, AGENT li
3� I
- m Phone�
w w WILLIAM D. BENIEVICH
Ls State License Approved
wa U 1/ PLUMBING INSPECTOR Ll�
FIXTURES
NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater
Size —
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen §ink
/ Not Conn.
Dish Washer
Sewer Box
Waste Disposal
ig Machine
Softener
Comb.Sink & Tray To Curb
Dental Unit
Floor Drain WATER SYSTEM
Hopper Size
Ixture Mee
Area Drain �� Main Drain Fee l�J
Water Leader Storm Drain Fee ' --�
Total Fee