1653 (2) ab LOT No.
NO. ® SfAMI
SAP PLIC
OR GAS PERMIT '
f WIAY 11 I UPERTINO
APR
Date PITY �� IRDCDl7[�t5111 Permit No. �
Wo I M
Fee $_�4—
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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 all other laws applicable thereto.
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Use of Premises
Cn Owner�L=LcL�s/� � Address
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By Address
CONTRACTOR, ENT
Phone —, Approved
UMBING INSPECTOR
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