2715I.•J - �.. // �Q. LOT NO. /J
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APPLIC�jj N FOR GAS PERMIT
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3 a DatMCTYl C PER 1� 1(1;96 S` Permit No. r S
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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
i N and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all /o/the laws applicable thereto.
0 o Use of Premises ` <<S /'J16'- e6
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3 Owner �i¢2/� t�.EUito Address dQ dOAY b,3hl-
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O CONTRACTOR, AGENT
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State License �G9.,L' Approved
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PLUMBING INSPECTOR
of Appliance I Units Fees
NAME TYPE
HOUSE GAS PIPING
Number of Outlets 1 V Size of Main
Gas Piping Fees
Tested and Approved ......... . ................. ......
DATE INSPECTOR