2616 (2)LOT I&
®'APP IZMAN1FOR PLUMBING PERMIT
t141AR 1 1964 ff,
OF CUPERTINO
Sanitary No..
Dar •�I96� Permit No
t�11 1 '/ O
Fee $�(�
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
rnon
State License -`�Approved Com/
PLUMBING INSPECTOR
Water Heater
Sewer
ze
UNITSI FEES I
Area urams I 1 II Main Drain Fee I :Zi, 1;'A
Sprinkler Vaives I 1 II Water SYS. Fee I /,�;O
RECORD OF INSPECTION