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1018 MA'wy
No. Street Lot No. S 3
— F."'17S
CATION FOR PLUMBING PERMIT — 13 V, 7-f
® (m� CITY OF CUPERTINO
1
I NOV n 3 1 70 Sanitary No.
Date 1 3 11910 Permit No. /4
Cu7Y QF COMM�UPEFee S '1",'510
pplica ion 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 the City of Cupertino, and all other
laws applicable thereto.
Use of Premises
Owner QUERN Cb [JST. co ,
By5H.J .1oS6- n4ctaot llcAtyL.
Contractor, Agent
Phone 2 -NS- -10-E4
State License "4 ZS!;"
Address Ibbs KMrtQ& WG S.3 .
H-19. o .�
Approved
Plumbing Inspector
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units
I Fees
Water Heater
Size a"
S /
Water Closet
i2
Material C. t,
Bath Tub
To Curb
Shower
8
To Prop. Line
Lavatories
t Z-
To Existing
Kitchen in
Not Conn.
Dish Washer
Waste Dis osal
Wash Tra
STORM DRAINAGE
Washin 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 I
( r
Restaurant Sink
Material C
Sand Trap
TOTAE FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
�0
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
I /
Gas Fee
voi
Vac Breaker
Skimmer
Filter
Permit Fee yDj
Total
1$
Total Fee C11,
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