1125 LOT NO.
NO. STa6aT
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--APPLICATION ':-FOR, APPLIANCE PERMIT
� OF CUPERTINO
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Date,� {Z4�1�7 ; 2— -196..... Permit No.
CITY or:, rI'DERTINIC Fee r
1_ 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 rode of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises
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Owner _ Address
Address
CONT0.AC , AGaNT _ WPhoneZj ��Y750
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