2701�Si ql,�r�t -u-.,. �. LOT NO.
APPLICATION FOR GAS PERMIT
FEB 2 8 1964 CITY' ,OF CUPERTINO
Date wv '� ip "'`.'196 � Permit No. 0
:1 ( LI 5
Fee $
Application is hereby made to the City of Cupertino for a 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
Ownercl�v�-c11e_ f�_-r-'
By
CONTRACTOR, AGENT
nL,..._ 4-- ,) 1 -� i
State
Address
Approved
PLUMBING INSPECTOR
of Appliance I Units Fees
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main 3/
Gas Piping Fees
Tested and Approved ._...�1..�...... ......_ n ...... ...............
DATE INSPECTOR