2219LoTNo.
NO.
® S13E
® - - C ON FOR GAS PERMIT
N
W = 1963 OF CUPERTINO
1°
APR 1
3 ¢ Date"� 196— Permit No. ���/
57
CITY OF CUP Fee$
o Application is hereby made to the City of Cupertino for a permit to install gas pipes
o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
> and/or appliances in accordance with the provisions of the Plumbing Code of the Cit
a m of Cupertino, and all other ws licable theret i }
0 4 Use of Premises .
00 L
�
3 Owner %%�`L+ • ��.,•� . AM tRnwu-a.,C.cQi Address Gi�
oa
2J
J o By Address
3 o CONTRACTOR, AGENT
Lfhone�G J- to 7J
wtate License Approved-
–U
PL[IMBING INSPECTOR
of Appliance I Units Fees
NAME.
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved ......./..�.. . .. ...........................
DATE INSPECTOR