2728:JAI
LOT NO. /7
ROl
O FOR
GAS PERMIT
C OF
C CUPERTINO
TMAR V /
Date - J'T , 196 Yl Permit No.
Wly ff CI�PE�TiNQ Fer$ /S
i anon is here y ma a 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
Owner `G4'(-jwniti/ltt_� pS " Address
By X-(? .
�C,O/NTRACTOR, AGENT
Phone.
State License n5^A?
w
PLUMBING INSPECTOR
of Appliance I Units Fees
NAME
HOUSE GAS PIPING
Number of Outlets z Size of Main
Gas Piping Fees /``
Tested and Approved ........'....'_ �..,.... ..._..... ..................
DATE INSPECTOR