916 (2) c va-i �1 r- G 11 ( a tJ Rd LOT NO.
S *ITY
SEP 28A LIN FOR PLUMBING PERMIT
OF CUPERTINO
C? , 19L Permit_No. `1�^-� �o
�. Fee $
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 in accordance with the provisions of the Plumbing Code of the City of
Cupertino, and all other laws applicable thereto.
Use of Premises l )i t l u ` o o t-a
:a
a,
W) Owner Address
By, -� / Addres
CONTRACTOR, AGENT
Phone /`/2 ;AC; > G Appro
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\ PLUMBING IN PE OR
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Ytf, the 'undersigned dohereby certify that I an,
the owner and occupant of the single family dwelling at
o�osS M C !QriAr� 2d, £or which I an making
application to do U M 6 e ;;,),work 'a-s a home owner.
I also certify that I will not hire any non-1 icens-ed
u 6 or contractor, but will do this work myself.
TELEPHONE igMER SIGNATURE