51068,/ UVIY 1 I ri //')/l� I/t ✓ r LOT
Y NO. SIAEEI'
j® PT N FOR PLUMBING PERMIT
C Y OF CUPLRTINO
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3�MA Sanitary No. �p
o Dat 11 `3 Permit No
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CI Fee $
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0 Application i ferr��j the City of Cupertino for a permit to install plumbing
°o 1- pipes and/or fixtures IistedtildI� erse side hereof, and agrees to install said prices
> i- and/or fixtures in accordance w�rtl'i'Hfe provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
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Use of Premises
00
0 3 Owner Address
zBy �LI'"'tp/G 6. Address /),-o cs k0l.
O qCONTRACTOR,AGENT
3a Phone
N
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0 f State License/ z ` 7 Approved
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U PLUMBING INSPECTOR
FEES
Ins
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final