NO PERMIT NUMBER (5)No. Street ���'�?CA!�IfON FOR PLUMBID
ERMIT
0 'l tY6
Sanitary No
Lot No.
Date riTV,If-ICUPERTIN0 Permit No.
Fee $ -f`
Application is hereby made to the City of Cupertino for a permit to install plumbing 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 Cupertino, and all other
laws applicable thereto.
Use of Premises
Owner7�7D/>/
By
Contractor, Agent
Phone
State License
/1
Address L/ z/ O k L �M C T
Addres%*�66 U/.O B/6
Approve
P bin, Inspector
Water Heater I 1 II Size I I
Wash Trav I 1 II STORM DRAINAGE
Comb.Sink & Tray �� To Curb
Dental Unit
Floor Drain �� WA'
Hooper Size
Water Svs. Fee
Total Fee