2695LOT No'
NO. ®% 'STREET
1T�
N I�jp-\�APPLII3ATION FOR GAS PERMIT
z a CITY OF CUPERTINO
W o ?FES 281964 ¢'
0 a Date 2�2 - o 196 '/' Permit No. �v
3 co OF C ��'t :. Fee $
0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i m and/or appliances in accordance with the provisions of the Plumbing Code of the City
w of Cupertino, and all other
laws applicable thereto.
Use of Premises
00
3 Owner Z"n'� ���-r/�-°� Address
Z J
Z By Address
0 CONTRACTOR, AGENT
3�
- N
Phone% - S
wz
oState License,2 � -�� Approved
U PL PG1 15 PE• 1 R
of Appliance I Units Fees II New
NAME TYPE
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved... ....—."'J.'�.... ............................
DATE INSPECT00.