NO PERMIT NUMBER (5) /
/Q� I /M/ _c �/♦,/`�LGL LOT NO.
NO. �G
NO. STREET
APPLICATION FOR PLUMBING PERMIT
CI P TI
Y 00 R !T 1
4 30 Date � `P
�, �� r
� BGrmit Pee;$ 0= 4 O
o Application is hereby made torlhe•�itY6p Cupertino for a permit to install plumbing
o pipes and/or fixtures listed on the re�ersp side rea�, 9 es to install said rices
> r and/or fixtures in accordance with the provisions of ffie"Plir'mTng Code of the City of
<w Cupertino, and all other laws applicable thereto.
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a Use of Premises Q S '
J4
O O n +
aa Owner(I /. /rfrN___.D 45 #9 _ Address�ex
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z By C�SW�sa
4iD.r 9n
O CONTRACTOR AGENT 625 Charles Street
Phonea99 oSSG San Jese, California 95112 ss+' ttJJ
oState License 17JS3� Approved
V x PLUMBING INSPECTOR
�JDFIXTIJRES NUMBER MAIN DRAIN
UNITS I FEES UNITS FEES
Water Heater I 4S�I I Size 9
Water Closet Material �.
Bath Tub To Curb
Shower To Prop. Line
Lavatories Ot2 To Existing
Kitchen ink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine /, Size
Water Softener Material
Bar Sink To Main
Comb.Sink&Tray T r
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size ,S
Restaurant Sink Materialz'
Sand Trap TO'T'AL FEES
Urinal Fixture Fee Z2,90
Area Drain Hain Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skinvner
Filter
Permit Fee
Total / 00 Total Fee