51039 092 O a L - p "be LOT NO.
NO. SnEFT
APPLICATION FOR PLUMBING PERMIT
< CITY OF CUPERTINO
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ro Sanitary No.
O Q r 196�r Permit No
3f JUN 22 1967 UWFeJ'd
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' Application is hereby made to the City of Cupertino for a permit to install plumbing
°o �p�Rean /Ar FSy s listed on the reverse side hereof, and agrees to-install said prices
r < landd 0r Ireri
ith
a wCupertino, and all r sthe provisions of the Plumbing Code of the City of
w liable thereto.
< „ Use of Premises
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3 Owner-I Address
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z By /xs<tA. -�t.,..e�.+.�r-�l Address
O CONTRACTOR, AGENT
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- m Phone ;7—
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oState License ��O 9 g 3 Appros_
U PLUMBING INSPECT �/
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FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water IIcater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink 'I'o Main Drain
Comb.Sink&Tray To Curb
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size r
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee s
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee S
Relief Valve Gas Fee /, f, e)
Vac Breaker
Skimmer
Filter
_ Permit Fee J. J
Total i D Total Fee I