NO PERMIT NUMBER /" � S I l ` ` LOT NO.
APPLICATION FOR PLUMBING PERMIT
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o Application is hereby mad (tNP-�.dyr2o( dt*tin permit to install Plumbing
o a pipes and/or fixtures listed on the reverse side hereof, an agrees to install said prices
and/or fixtures in accordance with tqheprovisions of the Plumbing Code of the City of
<w Cupertino, and all other TITYP"OFe WPERTINO
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Use of Premises
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r 3 Owner`Q C,0 � � Address /01 `tljVy'�
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CONTRACTOR, AGENT
3 < Phone 3 2 a �1l �3v3
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a o State License Approved
U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
atchnnks,
eate Size
Closets Material
bs To Curb
To Prop. Line
es To Existing
Sinks Not Conn.
ashers Sewer Boxes
isposalsrays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Com . Sink s Trays To Curb
Dental Units
Dunking Fountains
Floor Drains WATER SYSTEM
Hoppers ize
Restaurant Sinks Material
San raps TOTAL FEES
Urinals Fixture Fee 3 O`
rea iB.
rains aDrain Fee
Water Leaders benrBxattr-Fee
-prinklcr Valves Water Sys. Fee
Permit Fee
TOTAL t0 TOTAL FEE O
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final