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No. Street Lot No. 3 S
V2
PBICATION FOR PLUMBING PERMIT
�J �CITY OF CUPERTINO
6 19 1 Sanitary No. %102 B.F.
Date 11 Permit No. SII
CITY F I Fee $ W� S
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
Owner palE2y C.e kysT- GO Address
By $Awl rj E(,NFr,3jLA(- 10( -
Contractor, Agent
Phone 3--15- 6i044-�
State License 3L(.4 18 S
Address Ibl.$ 1RzOC25 Aub 'S,J
Approved
J"Plumbing Inspector ��
FIXTURt Coar+T GK g/7.
Dish Washer
Water Softener
Floor
MAIN
Curb
Size
Water Sys. Fee
Total 6t I II Total Fee I —t#
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