51075.1 (4) gar I REFI LOT NO.
h0.O. STREET '�•'I•
APPLICATION FOR PLUMBING PERMIT
AV
r i�if.�T CUPERTINO
x o Sanitary No.
o a DateG 268 Permit No
3� Pee $ 0
1 LL
' 0 ApplicGITYis 0C bXU ERT4K
e of Cupertino for a permit to install plumbing
`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
a w Cupertino, and alother laws applicable thereto.
0 LL Use of Preml s
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0 3 Owner + ress
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o gy �n 00-W lC e r t- Address
3 F qCO �R, AGENpT
— m Phone / Sp S 9
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Approved
tL.p.✓ WILLIAM D. SENEVICH
a o t
State License
U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEESUNITS FEES
Water Heater Size
Water Closet Materiel CZ
Bath-Fub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen §ink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washin Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tmy To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
d Tra TOTAL FEES
Urinal Fixture Fee 16d. S-0
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
kBreaker Water s.Fee
Gas Fee
Permit Fee -
Total 147 /Od, Total Fee oSb