51118 ode LOT NO.
NO. STR I'
c99 *R1. _� 1FOR PLUMBING PERMIT
OF CUPGRTINO
xo AU� 17 1966 Sanitary No.
� 4
o a Date 196 C,C, Permit No
3� $CITY QE CUPERTINO Fee 6-04116-0411w —
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o . Application is hereby made to the City 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
i and/or fixtures in accordance with t ),,visions of the Plumbing Code of th City, of
a w Cupertino, and all oth laws ap> ab thereto.
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LL Use of Premise
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AC 8AN I Go
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3 Owner Address
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J zDy. Address
O CONTRACTOR, AGENT
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Phone Vg7SY
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u f State Licenset1q � ' cf, Approve
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_U�/ PLUMBING INSPECTOR t/
11 Ix I URE�
UNITS FEES UNITS FEES
Water Heate $ize
Water Closets Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn.
Dish %Vashers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Cam . Sink s Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
San Traps TOTAL FEES
Urinals Fixture Fee 7.00
rea Drains Main Drain Fee
Water Leaders Storm Drain Fee
Water Sys. Fee /� NC
Permit Fee
TOTAL 11 TOTAL FEE
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final