2034 �J(
LOT NO.
NO, 5TREET
P, CL�i
ION FOR GAS. PERMIT`
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OCT a 19V� Y OF CUPERTINO tC _
Date JV , 195_ Permit No. O�
CITY OF CUPERTINO Fee $
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
OC of Cupertino, and all other laws applicable thereto.
Use of Premises `�'�
Owner Address_
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By 'Y IAHt,Q�,c_¢_ Address
CONTRACTOgg;;AGENT
Phone ? crQ rQ o X Approved
PLUMB)NG INSPECT R
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(o t` i OFFICE
IIVn GAS SERVICE NO ICE
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BUILDING INSPE OOS OFFICE
CITY OF CJkNTI I/NO
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You are hereby aut/hof'zed
`to c�onJ�,ect t e GA servic or
Owner or Tenant _..L
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No. of Meters ---------------- Reconnect
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No. of Add. Meters Move Meter
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PLUMBING INSPECTOR
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