2791-�aoa✓ ( �i LOT NO._•
S E T
APPLIgfrfON FOR GAS PERMIT
` ® OF CUPERTINO
W = �q 17 1964 1
Y0
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3 V D"et E `^!�/ 19/ � Permit No. -c279
11
Pee $
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o Application is hereby made to the City of Cupertino for a permit to install gas pipes
o 1- and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
= ie and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all other la applicable thereto.
v x
0 o Use Of Pre ises
oa Owner / Address/
2J
U
z By - Addres A0
O CONTRACTOR, AGE
¢Ia State License �%� Approved �-
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_ U PLUMBING INSPECTOR
of Aooliance I Units Fees
AME.
HOUSE GAS PIPING
Number of Outlets S e f Maim
Gas Piping Fees
Tested and Approved .. .[..C
E
�.......�......................................
DATE INSPECTOR