2163 1 C? `t o /( � ' , o' LOT NO.
NO. ,
® PPLICA I FOR GAS PERMIT
PEA,
2 9 99W ERTINO
Date — ` ��A —� Permit No._�i—�`�
11'YYYVVV Fee S_
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
of Cupertino, and all other laws applicable thereto.
Use of Premises
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v Owner " ` I Q Address _ 1
By Address Q�
CONTRACTOR, AGENT
Phone L Approve
PLUMBING [NSPE
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