100010/03 Cj WO I- /- LOT
NO. STN ET
APPLICATION FOR GAS PERMIT
CITY OF CUPERTINO
Date /6-CrV /f% , 196Y Permit No. D Q
Per $
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 instal said pipes
and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto. -
Use of Premises
..�
'/-oP N�LSon/
Ow,ne//r
gy/70 VfR / %f7
CON'rRACI'OR, AUEVr
Phone ;? 1- ' Z 3 3-�
3
State Licensee 31g2—
0366 GULF Ajd,
Address
L'%L P/z�iiv'u
Approved
P MC J Y�5 I�.CTOR
of Appliance I Units Fees
TYPE
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees , d
Tested and Approved .......... ._....._.._�................ ...SPEC_0R............_...
DATE INSPECTOR