557 (2) LOT NO. �-+ -
NO., STRE!
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L TION FOR'GAS PERMIT
ICUPERTINO-
To
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\ Date S Permit No.. �L z
r CpT�p�/� Fee $ i
I_ ApJUTtl n Qpere adeli,D11NOty of Cupertino fora 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 C '
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r7i Owner=(A Cr,Qz' J;I n0�11 U;- Address
Address] V e,sr ,. KeoQ oca(f�l
` CONTRACTOR, AGENT _ - ,
Phone Yln : (7.''!7 5 b t APProved
I l I I I , PLUMBING INSPECTOR
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