2180 (2) LOT NO.
NO. STREET N-,W- -
APPLICATION FOR PLUMBING PERMIT
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W Z CITY OF CUPERTINO
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o Sanitary No..
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< Date , 146_3 Permit Nn.
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. Fee$ 36 '�
' 0 Application is hereby made to,the City of Cupertino for a permit to install plumbing
o < pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
i N and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
< w Cupertino, and all other laws applicable thereto.
S LL Use of Premises
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o a Owner ,11!!;x/, 'Z�1/d,;;0<. Address
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A o By A//•1 1 k��r � C- Address��' A-V S��
t CONTRACTOR,AGENT
W WApproved. .e .. A IN .
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a o State License:�C J' f e-
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PLUMBING INSPECTOR
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