100010/&3S U
D4)c:'-
LOT
V " APPLlON FOR GAS PERMIT
a z I A P R 1.41965 OF CUPERTINO
Y 0 _
a' 4
o f D�tq 196 3 Permit No. O 6) O/ O
u lil
0 Application is hereby made to the City of Cupertino fora 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 City
< W of Cupertino, and all other laws applicable thereto.
,. Use of Premises—
o_o
> 0
F 3 C
O a
ZJ
J Z E
O
F CONTRACTOR, AGENT V (/
—W Phone
7-�2 —%p3 3C
e f State License Z•5 3 / Approve
a o
_ u 'LUINIBINC INSPECTOR
of Appliance I Units Fees 11 New
Heaters
NAME.
✓ HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved ...... ......:............. ......... ...............
..._.
DATE INSPECTOR