1187 �O O `._ (JCKN/L C/W� iP• LOT NO. /3
.�:� . NO, STILOT
TJfSANfi—
APPLICATION. FOR GAS PERMIT
CITY OF CUPERTINO
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Date1�1 Permit No.
CITY OF CUPER i Aw Fee s 421?.0-M,
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.
v
N
Use of Premises
v ,
Owner Address
By Auk Address
CONTN CTOR;'AGRNr .+*....
hone o?-oT/ � Approve
PLUMBING INS `.0 R
Remarks (Check d) '
Type of Appliance I Units Fees II New I Replace I Relocate
Gas Rang I II I
Wall Heaters I I I I
Gas Plates
Circulating Heaters
Blower Furnaces
,Gas Fired Boilers
Warming Ovens'
Percolators
Griddles
Steam:Tables- 1 I II I I
,ul;naceso ,ti I I I
as 'aUFl,r � I ii
I I II I
Miscellaneous
NAME TYPE) I I I y
I I II I I
I I II I I
I I II I I
pp IanceFees I I ��
inspected and Approved ..... ........ --- - .....................:...... ....
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets I 1 Size of Main I S�
Gas Piping Fees 1 I '
Tested and Approved ._ ..�5l.....L. .. ...._. ...... ......................
DATE INSPECTOR