51022 21*51O /Pr-Ace—
No.
ace—
No. Street Lot No.
o —
CITY OF cul'saWO
APPLICATION FOR PLUMBING PERMIT
A�}R q CITY OFCUPERTINO
U ' PR J 0 1971" " " Sanitary No.
E P * 1 .D• 1196— Permit No.SIO.Z oZ
3
Fee S �e^'
s Application is hereby made to the City 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 fixtures
o ro in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
laws applicable thereto. I
A n Use of Premises aS'"C
U /- � (f
o' o Owner r,#jh 'rt EG0Z/Q.—t Addressq/' C �F'r/aces
By X 5cl,e ei Address
Contractor,Agent
Phonetb
—k.0 State License Approved
Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Pron. Line
Lavatories To Existing
Kitchen Sink 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 Tra TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
W Otnrm Drain Fe
Sprinkler System Water Sys.Fee
Vac Breaker
Skimmer
Filter
e ee
Total Total Fee