1450 Lar NO. 02 3
NO. sTRBB
® PP.LI A; J,, N rFn0R APPLIANCE PERMIT
� 7Y OF CUPERTINO
P
O Soca
Date v � � , 196.s Permit No.
CITY OF CUPERTod'd€� Fee : 5
�> Application is hereby made to the City of Cupertino for a permit to install
gas appliances as listed on the reverse side hereof, and agrees to install said
appliances in accordance with the provisions of the Plumbing bode of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises
17i Owneroo�'�-`�''L Y hdress- _
BY Vc Co Address W. SgisC va/os
CONTRACTOR, AGENT / w
Phoneme 9.f- 1/ P ApprovedC� 1 [�
'PLUMBING INSPRCT
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