51172 (3)/o / O o . Oji /✓ LOT l:O.
ZpXErN Q S
A P 1 TION FOR GAS PERMIT
APR 6 1966 ' ITY OF CUPERTINO
Uate1966& PermitNo.
CITY_ Fee
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 City
Of Cupertino, and all ther laws applicable thereto.
Use of Premises 1-l- /c -
Owner `v�P D eta w�-(r C- Address /6)% r�0 '' *4W/
By d/ �p�3 Addr. ss / �0�' C 71,
By
CONTRACTOR, AGENT
Phone 78 g 5--85— ✓'
State LicenseL ! 7 V Approve k
�d/ PLUMIIRING INSPECTOR
of Appliance I Units Fees
(NAME TYPE) - 11
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved........._.........__...................._._..