51167.1 (2)I LOT NO
NO. STREET �
A PLIC TI N FOR PLUMBING PERMIT
f�e I F CUPERTINO
�l Sanitary No. Sid
I 6 1967 " �
Dare 196—JPermit No
Fee $ -2-6, SZ%
Appl2aFd1 i{h7rebrrADERTAINOT 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
By Z` eP rn/ /I-°flx-si
CONTRACTOR, AGENT
Phone � 3� - 17' 3� 1—?
State License
Address
id • �1 ' 9
Addrn ess
Approved X
I - PLUMBING INSPECTOR v
FIXTURES NUMBER MAIN DRAIN
UNITS I FEES UNITS I FEES
Shower I / I II To Proo. Line I ✓ I
Kitchen 5ink / Not Conn. _
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Si ze
Water
Comb.SinkBTrey I 1 11 To Curb I
Floor Drain
WA
Fee
Area in I� Main Drain Fee
Water Leader Storm Drain Fee
Total