51177.1I D 7 i S S I L /? LOT NO, I
NO. STIIEF.T'
CITY OF CUPERTINO
a My Of CVPW q,PPLICATION FOR PLUMBING PERMIT
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r o JUL 7 Sanitary No.
0 Date 19 — Permit No
0 P I 1 D Pee $
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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 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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a Use of Premises (�
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3 Owner U' W r C /% Address/ U t/ /%L Af S
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J z By R", /", Address /77�
o CON A TOR, AGENT
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s State License 7 Zai ApprovedWILL1AM D. BENEVICH
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— U PLUMBING INSPECTOR
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Units
Water Heater _ I 1 II Size I I
Waste
Water Softener I 1 II Material I I
Comb.Sink & Tray To Curb
Dental Unit
Water Svs. Fee
Total