1284 (2) LOT NO.
NO. STREET
FpR PLUMBING PERMIT
VOCT 2 ��s� TYOF CiJPERTINO
D 195_ Permit No. /-2
CITY OF CUPERTINO 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 otherI applicab the to.
Use of Premises Q
Owner 7Vo_ Address
By A91k A
�/� � CONTRACTOR, AGENT
Phone-AL -O _ Approved
PLI MBING INSPECTOR
w�I 'a y0 <. :� > w H C x m u uIv Wo �7i y 1� .1�a
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I, the undersigned do hereby cc till that I am
the owner ark occupant of the �sin�le f mi y d olling at
i
for which I am making
application to do work as a home owner.
so certify that I '11 not hire any non licensed
or contractor, but will do this work myself.
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