51177.110 bio
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��tmp CITY OF CUPERTINO
" < ar'I Of - APPLICATION FOR PLUMBING PERMIT
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¢ a MQI 1 1971
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Sanity No..
o Date / 197L Permit No % ll %
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P A I Fee �
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Application is hereby made to the City of Cupertino for a permit to install plumbing
o pipes and/or fixtures listed on the reverse side hereof, and agrees to install said rices
r and/or fixtures in accordance with the provisions of the Plumbing -Code of the City of
In
Cupertino, and all other laws appli ble thereto.
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r� 0 Use of Premises _
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6 J.467 it / Lao 7oxC5 Avi
r 3 Owner Address O
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By
CONTRACTOR, AGENT
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p 4
� o ate
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License
Add
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Approved
PLUMBING INSPECTOR
Waste
Size
Comb.Sink & Tray�� To Curb
Dental Unit
Drinkinc Fountain
WATER
Total Fee