2718 (2)LOT NO. /10
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APPLICATION FOR GAS PERMIT
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3 ¢ Date ��Ta DG T�°196 Permit No.
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0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
o 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
a w of Cupertino, and all othe laws appl. cable thereto.
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Use of Premises
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3 Owne , Address
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oState License I Approved
U I PLUMBIA'�G INSPECYOA
of Appliance I Units Fees
NAME TYPE
HOUSE GAS PIPING
Number of Outlets I t I Pize.0 Main 1
Gas Piping Fees i
Tested and Approved '`��
DATE 1 INSPECTOR