5118910 144 h Aky
No. Street
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ICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
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Nov 31970 Sanitary No.
Lot No. 2 5
2 - T3 4N115
2 - F vN yrs
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x Date i 3 , 147 Permit No.
3 CITY OF CUPERTINO Fee $ so So
$ 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
c 'c laws applicable thereto.
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Use of Premises PrpT,S.
By <5 A-Aj .10Sti MEC.NAid ICAC I
Contractor, Agent
Phone 2'1 S - R 0 +a
State License��2A�AS
Address
Address IL'5 q,4QrE4Z5 /kVE� SJ .
Approved
]umbing Inspector ;/
Units I Fees
Water Heater I 1 II Size LL" I I few
Waste
Wash Trav I 1 II STORM DRAINAGE
Comb.Sink & Tray I �I To Curb
Dental Unit
Material
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