5115746L LOT NO.
® I ION FOR GAS PERMIT
-W ` OF CUPERTINO
w � /AUG 3 1965
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3 < I�,Ity Z 19Z Permit No.f %
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W Fee $
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� Application is hereby made to the City of Cupertino for a permit o install gas pipes
'o 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 he Plumbing Code of [ At City
< m of Cupertino, and all other laws applicable thereto.
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0 Use of Premises Lz
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3 Owner ��y CLO ddress 2
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Z By���? Addres _ 2
� ONTRACTOR, AGENT
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— m Phone= -'5—C7
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aoState Licens�Approv��e
PL fBU � ING INSPECTOR
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of Appliance [ Units Fees
EMiscellaneous
NAME. TYPE,
HOUSE GAS PIPING
Number of Outlets 9' Size of Main
Gas Piping Fees
Tested and Approved ........................
DATE.
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