1554m&- I U 0 o Lo, No. 2-2 -1
NOVvIAR
T
A T ON FOR GAS PERMIT
6 19620 I OF CUPERTINO
Date CITY OF ��1�5_ Permit No. ,X.lzi''
Fee $
C"q ea—
Application is hereby made to the City of Cupertino for a permit to install gas pipes
M and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
U and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises
y _
0
Owner Address 6i /_�_��� a
0
1� By Address
_ CONTRACTOR, AGEN
�(1 Phone ' /e" �// Approved
PLUMBING INSPECTOR
of Appliance I Units Fees
TYPE.
Inspected and Approved .............. :........... ........... ............... .............
.
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets—1 I Size of Main I 3�
Gas Piping Fees I a. oa I
�_J �
Tested and Approved ./Q &— 1...... ............... .............
MTP INSPECTOR