2621 !�A09AI/ ( i" ,, vZLC.�i I. —LOT-NO, - —'
NO. STREET
N a APPLIC 17`10N FOR GAS PERMIT
a OF CUPERTINO
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x '0 V NOV 8 1963
3 '¢ - - 3i - � 6a
a Date /mss19fx� Permit No.
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= LL (;ITY �F CI�PERTi{�IO Fees.�- an
° Applicati n is here y made to the City of Cupertino for a permit to install gas pipes
o a and/or gas appliances as listed on the reverse 'side hereof, and agrees to install said pipes
i a and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all other laws applicable thereto.
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Use of P'emis s
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3 Owhe Address I'd 7� 3
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By �t ur
2;G2 Address
3 F _ CONTRA OR,AGE19
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rc a '! 3 . APpioved
o State License `
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1 i i A. I i .PLUMBING INSPECTOR -
Remarks (Check V)
Type of Appliance Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit _
Floor Furnace
Miscellaneous
' NAME TYPE)
HOUSE GAS PIPING I�
Number of Outlets Size of it ain Iiir
Gas Piping Fees -�
Tested and Approved . . .. .y ........ ..._. ........................
DAT � ���I : I SPE(;TDR lir