100186ILOT NO.
Nn. STREET
4' t -APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
oa Date�� 196Y Permit No /0 O,, /�8G
36
i n I Pee S
O 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
> and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other la appI cable thereto.
~ ~ Use of Premi es
00
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3 O er Address
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By
X Address
CONTRACTOR, AGENT /
3 r ��2b e LL•e: '��
— Phoneme
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° ; I , VJ.LLIABS D. E=','—','!CHu s State Liccnse�,7s (. GY Approved
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U PLUMBING INSPECTOR
I
`X/ater Hcate
nes
Va
Fixture Fee
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Hain Drain
Final