1599 (-rS n - `J LOT NO. •,�
NO. STR88T ' '
)APPLICATION FOR GAS PERMIT
mQF CUPFRTINO
rxy
Date _ Permit No.
CIO
Fee $�
App IRI ieretl,� �0' y of Cupertino for a permit to install gas pipes
and/or gas app tanceS as Is edon t r rse side hereof, and agrees to install said pipes
and/or appliances •accordance w' the provisions of the Plumbing Code of the City
of Cupertino, an a other laws (pp�able theret
c
Use of Premi '
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�n Owner Address /n)
By Address D 7
NTRACTOR. AGENT' �
Phone ���� _ Approved %^
PLUMatkG INSPB TOR CC11
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I, the undersigned do herby certify that
I an -the owner and o cups yt q�7�p�� the singl l
fan:I '`dwelling atooz:a6 1 Vl Cje Fl,
for wh c I am making aoplica ionto do
work as a homeowner:
also cer y t I w ll not hire any
non-licensed or contractor,
but will do this work myself.
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