1625LOT NO.
•Np. `' . STREET -'s. • - . ,i ,
.lam �
" APPLIC/1TIdN FOR P MBING PERMIT
Cl C rIINO
' 1
195_ , Permit No.
Fee $
Application -is -hereby -made .O the City of Cupertino for a permit to install plumbing
pipes an4%or-f.);6 es -listed -on -the reverse side hereof, and agrees to install said prices
and/or fixtures in-accordance_with_the_provi'sions of the Plumbing Code of the City of
Cupertino, and all other ws applicable thereto.
t
Use of Prem�/is/`e�/s / J A
inn r � Address
' .�
Addres
CONTRACTOR,AGENT
4W1G11'NSPE4RP
honex %C�i`IA' Approved
c.sn
1.
FA
Ti
- I, , the undersigned do hereby c rt&�"rrfy .that .
I am the owner and occupant @.81 le
fa dwelling at fib z j i"'
or h I am making appli ation to do
work as a homeowner.
I a so c =,y ty I will ,not hire any
non-lice �_ or con-
tractor, but will do this v! myself.
TELEPROM-INUM—BER SIGNATURE