51001.3/OS/O '41,415woR711 U,Q LOT No.
NO. STREE.I'
-APP.LI A,TION FOR PLUMBING PERMIT
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rC(TY OF CUPERTINO
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3 < I)at. (OFC 26 968 196— Permit No����l. 3
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Fee 5 ii• DD
LL° nApplicafMn isrba}ebF made'fo)the City of Cupertino for a permit to install plumbing
o < pipes andN fixtures' IiVe'd no the reverse side hereof, and agrees to install said prices
'z to and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
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00 Use of Premises SOR/A/KL£ S 1/5%f N
r 3 Owners r*S ^.It, QWZNS Address
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CONTRACTOR, AGENT
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- < Phone Z3 6 0
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a o State License Approved .ea
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PLUMING INSPECTOR
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klcr Valves
I UNITS I FEES II 1UNITSI FEES I
Sewer
fixture
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complett
rain 4 / ���