1065 (2) LOT NO. /
NO. '--BTRBRT'
APPKATION FOR APPLIANCE PERMIT
CJ'j DEC y 7 1962 CE, CUPERT[NO
Date�t�/n/, i a 196.. Permit No.
CITY OF CUPERTINO Fee :
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 (7ode of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises iii ah 1'>
Ji Owner _ Address
Address
ONTRACTOR, AGP.NT
PhoneLC L -�3��`O Approv
PLUMBING INSPECT R
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