NO PERMIT NUMBER (3) l
c No. Street Lot No.
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APPLICA O I
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E Date4��-7b3.:'. /S, 196 Permit No.
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3CITY OF CUPERTINO Fee s
Application is hereby made to the dy of Cupertino for a permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof,and agrees to install said prices and/or fixtures
o in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
I
"elaws applicable thereto.
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" ; OGLE ��/!i%�f iEJcSiGi9yG�
a 73 Use of Premises �T
' ° Owner---7,/t' ��07y� `� Address--;;�"--36�3
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ayLisre Tiv/Z" 14—�Ls /.yam. A'a�aressy��sa>..�j•�-�y�o
3 Z Contractor,Agent
d ° Phone
-a� State License Approved - -"
L Plumbing Inspector J1/
FIXTURES NUMBER MAIN DRAIN
Units Fees Units I Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink 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 WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee •s—�
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
r'ooL TiAtG�
Permit Fee 6p
Total Total Fee O