100000LOT
NO. STREET
APPLICATION FOR GAS PERMIT
CITY OP CUPERTINJ/O
T� / 0n
Date LI 196 2�' Perrrrlr No.
/ S -z
Per $�
Application is hereby made to the City of Cupertino for a permit to install gas pipes
and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises �'�% Ad'-& ;
Owner Address 1 X193 41
By�io A04-� Address -%$
CONTRACTOR, AGENT
F 3C
State Li(
/s39 yL
Se - 7. f/
Approved
PLUMBING INSPECTOR
of Appliance I Units Fees 11 New
TYPE
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved ....... .......-j -._.................
' DATE INSPECTOR