100087 /GO"/VJ I ilLIC W
LOT NO.
NO. YYY STREE.I'
I ION FOR PLUMBING PERMIT
z ` ® OF CUPERTINO
x ° Sanitary No.
MAY
EX /
2 _
3 a Date 196 7 196 196_ Permit No
_U Y Pee S
LL � M1
° ��il at a �f��{3cie City of Cupertino for a permit to install plumbing
o , pipes and/or fixtures is c +� reverse side hereof, and agrees to install said prices
> I and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other lays applicable thereto.
4 Use of Premises Rag (9p
00
> m
3 Owner [>" Address
ZJ
z By Address/xaL'Se&Iej
O CONTRACTOR, AGENT
3 W Phone
z'o, IStateLicenseC';Z(-)960z7.$4- Approved""
PLUMBING INSPECTOR
`Jr ✓
HX I URES NUMBER
UNITS FEES - UNITS FEES
Water Heate $ize
Water Closets Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
aih Trays STORM DRAINAGE
Was ing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Com . Sink u Trays To Curb
Dental Units
Drin ing Fountains
Moor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
Sand Traps TOTAL FEES
nna s Fixture Fee
rel rains Main Drain Fee
7VY/ater Leaders Storm Drain Fee
5prink lrr 71. Water Sys. Fee
Permit Fee
TOTAL TOTAL FEE
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Hain Drain
Final