51167.2e No. Street Lot No.
0
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
CRY OF C:8"a:TIN0
MAR
-1 1 r� Sanitary No.
~ 1971
Date 196_ Permit N's� F_ % -L
P �� D Fee S]`3'
Application is hereby made to the City 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
in accordance with the provisions of the Plumbing Code of tlie'City of Cupertino, and all other
laws applicable thereto.
Use of Prem
Owner\�/)! , O /f/L 1
By
Contractor, Agent /
Phone \— 3-V—/-2.>-67� /
State License �'S` 7 / /�/ C :3b
Address
Add re
Approve
Plumbing Inspector
FIXTURES NUMBER
Units Fees
Water Heater
Water Closet
Bath Tub
Shower
Lavatories
Kitchen Sink
Dish Washer
Waste Disposal
Wash Tray
Washing Machine
Water Softener
Bar Sink
Comb.Sink & Tray
Dental Unit
Drinking Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler System
Relief Valve
Vac Breaker
Skimmer
Filter
Total
MAIN DRAIN
Units Fees
Size
Material
To Curb
To Prop. Line
To Existing
Not
Conn -
S DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size
Material
TOTAL FEES
Fixture Fee —
Main Drain Fee
Storm Drain Fee
Water Sys. Fee
Gas Fee O
Permit Fee
Total Fee �`u