996I
LOT NO.
NO. 5
® c bI
ON FOR GAS PERMIT
161960 OF CUPERTINO
Date 195_ f Permit No. 790
CITY OF CUPER Fee $�o
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 al jother laws a able therge A /?
Use of
f jPhone^ "
22C� _ Address
iw •. 1
• , � � � Approved 0 a Lim
� .. I .T � PLUMBING INSPECTOR. -
td,e undersigneddo hereby,°ce-rtif,y that I am
the was r --an cup,nt of the singlo,family dwelling at
'�• 'for which I am making
apjDlicaticn to do work as ahome 'r
of nc,
I also certify that I will not hire anjt non -licensed
•� or contractor, but will do this work myself.
TELEPHONE iU1iB
SIGNATURE