51028 103-111 3'11 I C2,,e,- ,/a, LOT NO.
NO, STREET
APPLICATION FOR PLUMBING PERMIT
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CITY Op CUP�� INo
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a Date ' "2
5. � EP 7 Pij 6it
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LL w Application is hereby made to thet�it;• of Cupe^tion for a permit to install plumbing
o a pipes and/or fixtures listed on the_,revcyrse Te here�f)Frgtl�agreej to install said prices
I and/or fixtures in accordance with the provisions o[ 0- luriTing Code of the ('try of
a w Cupertino, and all other laws applicable thereto.
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Use of Premises
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7 N -77
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Owner • , ,/tih�oQ� Address/03' '/,2 -
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By`�t�� O-'� ` J O—" ti Address ?94— ue
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— `m Phone c;? 5� -7— ;5"/O 7
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a o State License 7 5' /9 4�� Approved
f j U PLUMBING INSPECTOR
FIXTURES
UNITS I FEES UNITS FEES
Water Heate (J Size
Water Closets Material
bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn. .
Dish Washers Sewer Boxes
Waste Disposals d i
X ash Trays STORM DRAINAGE
Was ing Machines Size„
Water Softeners Material
Bar Sinks To Main Drain
Comb. Sink & Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
Sand Traps TOTAL FEES
rina s Fixture Fee
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
Tprinkler Valves Water Sys. Fee
Permit Fee
TOTAL 5"O TOTAL FEE s j)
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
�4ain Drain
Final