51167.1 (2)�ardx'1r-ig�l, LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
Y ON CUPERTINO
Sanitary No.
Date r, j N 196 Permit No. _5 6.5�
= Fee$C�
Application is hereby made to the City of Cupertino for a permit to install plumbing
Pipes an6�{5 fixtdre5 ll� �tr he•reverrse side hereof, and agrees to install said prices
and/or fitar�s irl�acco2d� deFw[h� the.provisions of the Plumbing Code of the Carty of
Cupertino, and all other I iws applicable thereto.
Use Premiiss�/jam
wner. �:Pr Address_
Address—
CONTRACTOR,
ddress_CO CTOR, AGE
phone—,
State License
PLUMBING INSPECTOR /
r >/
FIXTURES
NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater
Size
Water Closet
Material G/
Bath Tub
/ To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn.
Dish Washer
Sewer Box
Waste Disposal
Wash Tray
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinkin Fountain
Floor Drain
WATER SYSTEM
Hopper
Size
Restaurant Sink
Material
Sand Trap
TOTAL FEES
Urinal
Fixture Fee le..SZ
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee / 7
Relief Valve
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee =deed
1 Total