100171 LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
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S—�o i� �S—� � � Sanitary No.
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¢ LL Aln
o Date ? '1/1HK 196�, Permit No /00. / 7/
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LL M8 Fee
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Application is hereby made to the City of Cupertino for a permit to install plumbing
° pipes ant/or fixtu?es lisfed�on-therre verse side hereof, and agrees to install said prices
i N and/or fixtures in`accordatice withl the�piovisions of the Plumbing Code of the City of
< w Cupertino, and all other laws applicable thereto.
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w Use of Premises
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o a Owne 5��/l/T4/ �ZAddress /O/9/ '41
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J zB Address
° ONTR ,AGENT
Phone 1'S3 G.Z�9
ao State License Approved �✓/C�
U 1 PLUMBING INSPECTOR
I;lX,I URES
UNITS FEES UNITS FEES
Water Heate 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
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Comb. Sink s Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
Sand Traps TOTAL FEES
Urinals Fixture Fee
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
Sprinkler Valves Water Sys. Fee
Permit Fee
TOTAL TOTAL FEE d�
RECORD OF INSPECTION
Underground Rough...
Partial Rough..
Rough. Complete..
Main Drain
Final....