1391 (2) a
LOT NO.
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P �LyICA FOR GAS PERMIT
r AUG 3 � ,` pF CUPERTINO
DateQ�TV7Y OF WHRM095_ Permit No. �j
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• Fee $ •75 o
Application is hereby made to the City 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 appli le thereto.
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Use of Premis4s 'r lCl. ' �, �0
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Owner 7� + ac / tt2—�. Addre3 " " —
By� ����tif' r Address
CONTRACTOR, AGENT
— Phone Zl -./-7.3 �, ^� I I Approved
f ` PLUMBING INSPECTOR
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