1072 (2) LOT N0,
No. STREET
AP(�LI .-TI'ORIFOVAPPLIANCE PERMIT
Lt f� 4 CITYEE OF CUPERTINO
Date DEC �19< Permit No. d�
CITY Or C!1PERT!N0 Fres 1 i CO
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 code of the City
of Cupertino, andallother laws applicable thereto.
q Use of Premises Ar v .0 .
Owner (,�(I�JQ�O _ Address
/ Address
C NTRACToa, AGENT ,
Phone - u��0 Approved / ''
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PLOMBING INSPECT
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