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NO. STREM
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APPLICAMQN.n PMBING PERMIT
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i rc San •fr No. /sb5�7
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3 a vale E%cam 1968 +t NO s -//k 2
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LL w Application is hereby madeyo 01 -Ci�}��! nPP�{ttlr�q for a Permit to install Plumbing
isL*�iid'alKdr44,0nd 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 laws applicable thereto.
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Use of Premises
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3 Owner( g� 0 • Address ��- ���
z By0AI-10r0CZZL-fi ;- �CAddress PON '04��`T
CONTRACTOR, AGENT
3 u`' Phone
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QUState License
,\) %S.2%� Approved WILLIAM D. BENEVICH
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X PLUMBING INSPECTOR
Water
Wash
Comb.Sink &
Dental Unit
Size
Water Svs. Fee
I I II permit Fee 7. O
Total ��/9S Total Fee. J9_ .,7-/