51167 (2)LOT NO._
NO. STREET
m
,0 .1m APPLICATION FOR GAS PERMIT
< !J� CITY OF CUPERTINO
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Unre/� 196_ Permit No. J14/ 7
3 Ull T y ( /� Fee $ .-
° Applin&)Iis.hereby made to the City of Cupertino for a permit to install gas pipes
'o . and/or gas aplih pasll ted on the reverse side hereof, and agrees to install said pipes
> and/or appliances in 11a4dance with the provisions of the Plumbing Code of the City
< w of Cupertino, and all other laws applicable thereto.
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Use of
By i. 2:4o ir/
CONTRACTOR, AGENT
$tare
Address Lc't 'e /
Approved
PLUNBINC INSPECTOR /
Type of Appliance Units Fees �� New Replace Relocate
Gas Ranges
urnaces
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees f S
Testedand Approved ...... --- __---..... ,.... ,... .... ._.----..._— ............
_...
DATE