51146zQ
Wz
s
Y 0
0 4
� a
3U
W W
r 0
w F
oQ
zU)
aw
w I
t` r
J
O0 0
7 N
0 ;
0 j
ZJ
J Z
J 0
3�
—0
w Z
w w
a a
i0
—U
NO.
a.OT
STREET
APPLICATION FOR GAS PERMIT
CITY OF CUPERTINO
Date ' L/ 06-11�4Permit No.
0
Fee $ 4L
Application is hereby made 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 CI
of Cupertino, and all other laws applicable thereto. z',/
Useyof PremisesZ,n'��Q—f'�-�
OWRBCISLZ�J9LC=4sri��le�Gl�CI�
By C"
CONTRACTOR, AGENT
Phone
I
State Licensee= -7 3 l
Address
Approved
PLUMBING INSPECTOR
of AvDliance I Units Fees
Heaters
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets I I Size of, Main
Gas Piping Fees 16-061
Tested and Approved........................................................................