981 .22�Q C. PIT NO.
�RRPLI'CATION F19 R APPLIANCE PERMIT
OCT 11
�� CTY OF CUPERTINO
Date /r/dCdCd���++111LLLv///NNN 196.12, Permit No._Q�__
CITY. OF CUPERTINO
Fee $
Application is hereby made to the City of Cupertino for a permit t Install
gas appliances as listed on the reverse side hereof, and agrees to install said
appliances in accordance with the provisions of the Plumbing rode of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises .6L_h
JS Owner I ` ddl Address
By < < eo 0. Addres �6 57 edwco,4
LONTRACrOR, A BNr
Phone�_��I// 5'o Approved �
PLUMBING INSPRO R
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