51179 (3)4
t
/Lrr<� SCJ/./ilrL/ LOT NO.
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
Sanitary No
Date Permit No
f ((�;T 7 oC Fee 5 2 3, SZ
Applica iohOis`hTrPtS}��»�stk7to t t 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(���F s a cc �ance with the provisions of the Plumbing Code of the City of
CupertPr+tS,rand W ott sRT . thereto.
Use of Premises
Owner Address—
By f�-/t��J/t�lx4C/ Address_
y CON�TOR, AGENT
Phon'1 -.7 �1
State License Approved WILLIAM D. BENEVIC-4
PLUMBING INSPECTOR v
FIXTURES NUMBER MAIN DRAIN
UNITS I FEES UNITS I FEES
Water Closet I -�- 1 11 B1ateria'
Bath Tub / ro Carh
Shower / To Prop. Line ✓
Kitchen ink / Not Conn. I
Dish Washer Sewer Box
Waste Disposal
fl,
Si ze
Comb.Sink & Trey To Curb
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper 11 Size I I
Urinal Fixture Fee
Area Drain Main D 'in Fee
Water
Total Fee
Fee