8531 ULOT NO.
NO. STREET
APPLICATION FOR APPLIANCE PERMIT
CITY OF CUPERTINO ,
Date 196..._, .Permit NoS,4_
Fee s�
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 oLher laws applicable theret .
Use of Premises
Y Owner /b�7 ii �G✓ _ Address
AM Addrcss)c
CONTRACTOR, AGBNT
Phone Approved
PLUMBING INSP O
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