2700LOT NO, 14-1 //
'FEB�oPyICATION FOR GAS PERMIT
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wITY'OF CUPERTINO
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0 U Date CIY 9F -GRE -RT "'196 Permit No.
i Fee $
0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i a and/or appliances in accordance with the provisions of the Plumbing Code of the City
a W of Cupertino, and all other laws applicable thereto.
Use of Premises
00
3 Owner'4'1! � - Address
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� z By -�� Address
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CONTRACTOR, AGENT
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o f State License -/I& S %
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PLUMBING INSPECTOR
of Appliance I Units Fees
NAME TYP
HOUSE GAS PIPING
Number of Outlets 02 Size of Main
Gas Piping Fees
Tested and Approved ............._.........
DATE INSPECTOR