2058 (2) L a�02�i/.N/y���� LOT NO,
NO. 5 EET
N q� APPIL'ICA710N FOR GAS PERMIT
w i g"Or C_UPERTINO
° 10Ci 2 6 1962
3 R _ �� os
a Date 19G_ Permit No. _
° ph Ion id I r b I the City of Cupertino for a Permit to install gas pipes
o < and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i and/or appliances in accordance with the provisions of the Plumbing Code of the City
< w of Cupertino, and all other la applicable thereto.
Use of Premises ilkf �
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Owner dre- ss
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a < State LiccnscApproved,
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E?PiAsP10RA�RY GAS SERVICE
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REASON: ......... f
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The undersigned agrees to be responsible r the gas service at the above location
until the building is ready for occupancy, and is released by the Building Department,,
Cit}' of Cupertino. / /,
Phone(.. o7. ^fl --�----------
117 1/63--500/
INSPECTOR TENAftTOR?OWNER