1186 U
pp
I�o00 (/ /�/k/i� LOTNO. X-3
NO. ST99ET
WAPPLICATION)FOR GAS PERMIT
CI OFCUPERTINO
Date U f JAN'R/- W l,."t9aF'/ Permit No. I O L
n DD nn Fee $ cx•o
Application'�herby' ad'L�ttolth ity of Cupertino for a permit to install gasi
P pse
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 h/w',s applicable thereto.
�I Use of Premises �Ae—�
�n Owne ` Address
Y By W- � • �I ^Address �7
c Tancroa,
Phone oT-Si¢ j Approve
I ` PLUMBING INSPE&- <
Remarks (Check ✓) .
Type of Appliance I Units Fees II New Replace Relocate
Gas?Ranges
Will Heaters
Circulating Heaters
Blower, Furnaces �� _�, °:•a"
Gas.Fired Boilers
WarHW'ng Ovens �� '•
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor.Furnace
Miscellaneous
(NAMETYPE) �� � '- •�dl�;>�+
Appliance—F—ee—s----F 1 11 1 1
Inspected and Approved ..... ........:...L..-_............._...._.... ............
DATE INSPECTOR
HOUSE GAS PIPING
Number of OutletsSize of Main
Gas Piping Fees
Tested and Approved ... .. IVIZ...1. ... . ................:..................
a-OATH .INSPECTOR