511893 t
a \'I 4 P Q ;�
No. Street Lot No. 3 l
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�Y ��� �7.P I�IC TION FOR PLUMBING PERMIT
SAN 6 �y7� CITY OF CUPERTINO
�Y Sanitary No. 70 98 8.F
�Uai' C 1') & -ri 19-ze
y
Permit No.55 /�
Fee$ \\bs5
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 the City of Cupertino, and all other
laws applicable thereto.
Use of Premises 5
Owner Q1)E3?=,� CO QST Cn
By SA -.1 ,O&r. "ECkkp )tr-Ai- Ik)C
Contractor, Agent
Phone 2'IS— qn44
State License a-( 4 R�
Address
AddresslLeLS; 124(%625 AUS SJ.
Approved J
It-- lumbing Inspector
COUNT
Ot
FIXTURES
NUMBER
MAIN DRAIN
Units I Fees
Units
Fees
Water Heater
Size
$�
Water Closet
IY
Material c-i
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
I w
To Existing
Kitchen 'n
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 I
S�
Restaurant Sink
Material
Sand Tra
TOTAL FEES
Urinal
Fixture Fee
cl o
Area Drain
Main Drain Fee
Q°
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
S°
Relief Valye
I
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total
60
Total Fee I
l S°