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No. Street Lot No.
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v APPLICATION FOR•PL-UMBING PERMIT
E CITY`ORCOPERTINO.
0 Sanit�ry;No.
c / C
� Date
196�C 3 9 8 ,T' 7 Permit No.
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Fee $ 1, 06)
3
s Application is hereby made to the City of Cupertinolfor a permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof,and-agrees to install said prices and/or fixtures
o - inaccordancewith-the-provisions of the Plumbing Code of'the cCity of Cupertino,and all other -
laws applicable thereto.
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A A Use of Premises
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° Owner Address �s .$
-24
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Contractor,Agent
° Phone �6 a ��
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� .1�O ��'S�
— -��State License Approve
Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen in Not Conn.
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain 11 Main Drain Fee 0
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief Valve 11 Ggs Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total FeeIt. do