51187LOT NO.
NO. STREET
AP_PLICATiON, FOR PLUMBING PERMIT
_' j % TY OF UPERTINO
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1 F,
'X Sanitary No.
3 a Date G ��EC 1 MirIDA31 �� iPermit No, -� 1�_
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LL vfTy it Fee $ 3 SZ
' o Application'fs herebyrmad�,tptihe�rity of Cupertino for a permit to install plumbing
o pipes and/or fixtures listed on'the,,reversetside hereof, and agrees to install said prices
> 1- 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 ti
00 1
3 Owne44r_ u/ /7` / E/ Address�2/�29 ��� Q�
? z ByZC?O'/G � T!-� 0�7� • Address2 13-0 Ar e// �4.X/
J CONTRACTOR, AGENT T.
3 usi Phone �� 7` �SS /
a o State License-16S2�� • Approved
7I A PLUMBING INSPECTOR
I UNITS I FEES II IUNITSI FEES
Fee
/RECORD OF INSPECTION