51174✓/'� 3�LI/Ji:�V�CJ/� !SC`V/U• LOT ISO._
NO. EET
APPLICATION FOR GAS PERMIT
�� TY OF CUPERTINO
(SEP J.6 1966
Date 7` �� 196 '6 Permit No.
CITY OF. C�PI���C Fee S
Application Is e 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 alll�llther laws applicable thereto.
Use of Premises
AGENT
State License " ` J ®6
Address/
Address- t
l/r
Approved
LUMMNG INSPECTOR
of Appliance I Units Fees 11 New
NAME
HOUSE GAS PIPING
Number of Outlets 10 1 Size of Main
Gas Piping, Fees 1 1
Tested and Approved . ...... ....___..----i._ .............----.._. ... ..... ............
DATE INSPECTOR