1122 LOT NO.
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APPLICATION f OR APPLIANCE- PERMIT
QAH 17 j-Ha C'l�t.Y.'OF CUPERTINO
Date�IT�Z•/���z� ; 196..... Permit No. I I 1 Y
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vJ Fee Z
�` Application is hereby made to the City of Cupertino for a permit to install
n gas appliances as listed on the reverse side hereof, and agrees to install said
appliances in accordance with the provisions of the Plumbing c',ode of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises- o
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r7i Owner Address� 1
By. Addro'ss �/ h•
CONT0.ACT00., aNT
Phone�./N 6"/7 S =r r Approve���
�, I� -PLUMBING INSPa 0.
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