NO PERMIT NUMBER Iq9 Ate/ I / W I L l CG�/ `�• LOT NO.
NO. ST EE.T
APPLICATION FOR PLUMBING PERMIT
a CITY OF CUPERTINO
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, o � Sanitary No.
o a p .3 ! LI 196ff Permit No
3U Fee $ .2-r, J3
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Application is hereby made to the City of Cupertino for a permit to install plumbing
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'o 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
i w Cupertino, and all other laws applicable thereto.
j Use of Premises �S --
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1- 3 Owner u}14p ME: 3 Address
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f State License /74S A;? Approved WILLIAM D. BENcV ICH
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—0 PLUMBING INSPECTOR ��
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNI'T'S FEES
Water Heater /•5'n Size 14
Water Closet 3 q 5D Material
Bath Tub I :;71 To Curb
Shower / cn To Pro . Line
Lavatories An To Existing
Kitchen Sink / ,Sp Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tmy To Curb
Dental Unit .01
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap 'DOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee Q
Water Leader Storm Drain Fee �-
S rinkler Valve Water Sys.Fee I CD
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee d U
Total /a- /„pp Total Fee n