2066 ca�/ �v� ✓_//_iS A /J /l�,jf� LOT NO. �� c
No. STREET
Bp IC'A,ION FOR PLUMBING PERMIT
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��OI CUPERTINO
Y
W ff- ImAY 16 7963
0 a: Date - 196_ Permit No.
U Fee
°t " Applli-lt on QFherf�A)mAdRIlth1PCity of Cupertino for a'permit to install plumbing
° a pipes vtc{%qr,fix-eu}"'esrlimiid oil the revetse,;side hereof;.anil agrees to install said prices
> and/or"fizlures-in"acco'rdance will% the Pi visionsl
z V) ,6(E egPlumbin Code of the Cit of
w = Cupertino, and all other' a s aj>>IiGa th to:
rI
m Use of Premises
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N
. 3 Owner Address
o By �Cati a¢. /(- Address
CONTRACT
OR
W Y .l.r ._•_ - ..
°a o State Licens "Approved
r
PLUMBING INSPECTOR
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the undersigned do hereby certify that-
I "am the owner and occupant f the si e
family dwelling at
fo ich�Z am making. applica ion to do
work as a homeowner.
also cert i Ft—I will not hire any
non-license or contractor,
but will do this work myself.
ft.
asp- `Eay
TELPHO NUMBER