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NO. STREET
APPLICATION FOR GAS PERMIT
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i CITY OF CUPERTINO
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3 U Date 196— Permit No. --f—/ O 7S -
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0 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 , e provisions of the Plumbing Code of the City
a w of Cupertino, and all otl r laws ap able th eto.
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LL Use of Premises,
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Owner
y / �✓I, 77 ,/ Address
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O CONTRACTO ,AGENT
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- Phone a53 - 5560
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f State License Approve
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- U PLUMBING INSPECTOR
of Appliance I Units Fees
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Testedand Approved........................................................................
DATE