NO PERMIT NUMBER No. Street Lot No.
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(OCT 3 1968 itary No.
E Date "
6 Permit No.
3 OF CUPERTINO Fee$ S�
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
° ro in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
laws applicable thereto.
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Use of Premises C A LLV G
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— � Approved CF,
1� State License APlumbing Inspector ✓
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
Sink"Z q3 — 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 •5C, S-U
Area Drain Main Drain Fee
Water Leader Stom Drain Fe
Sprinkler System Water Sys. Fee
Relief Valve I Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total 1A S1 Total Fee "�