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C/PPPS
No. Street Lot No. �
o —
d AP ICA _ ,OI�P��JG PERMIT
Y QUPEo �OCT968�jntary No.
E Date �� _ , 196 Permit Na // .
° ((��II [[�p II�t''((�� Fee S 3. J�
z Application is hereby made to tqh FCitj�lbJPA RTtu1o.`M a permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof, and agrees to install said prices and/or fixtures
o in accordance with the provisions of the Plumbing Code of the City of Cupertino, and all other
laws applicable thereto.
L°. Q
m .0 Use of Premises
o (
° Owner (/,{�/yJ(- S JeU5/ le Z— Address 2 �J
�AddresZOC
BY 76i�fy- si
i%'//_ _ . _ ,
3 Contractor, Agent O.oN�iii�•
° Phone 0 3 % _ %63I
State License—,Ie? - 297297 Approved
1 ✓Plumbing Inspector J
Water Heater I 1 II Size I I
Waste
Dental Unit
DRAINAGE
To Curb
Size
Water Svs. Fee
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