1811 LOT NO.
Np _
' 7UOL4;TAllCUPERTWO FOR GAS PERMIT
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Date ,I M-2 Permit No. /91/
Fee $
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.
a,
Use of Premises— 3 F21+a r 4 N no LV
ro
n Owner_ Address
By Address l
CONTRACTOR, AGENT
Phonef✓-• —692-/ r Approved
PLUMBING NSPE R
Remarks (Check ✓)
Type of Appliance I Units Fees II New Replace ( Relocate
Gas Ranges
Wael Heaters
Gas Plates
Circulating Heaters
Blower Furnaces �-
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous II _
(NAME. TYPE)
I III I .-
I I
pp lance >:ees�— �—��—��—
Inspected and Approve ..............:_.L...................SPR.....G.TOR..._
Approved ......�.. .......
DATE. IN
HOUSE GAS PIPING
NumOut[ets I I Size of Main
Gas Piping Fees
Tested and Approved ........................I...............................................
DATE INSPBCfOR
OFFICE
COPY
GAS. SERVICE NOTICE
BUILDING INSPECTOR'S OFFICE
CITY OF CUPERTINO
....... ................ .............. 196...
To
You are hereby authorized t co ect the G s ry cep for
Owner or Tenant ............ ...
At.... .................Lt.)- .A.,.........:............. ... ......... ................................. . ........
New Service ..........................
No. of Meters ..�............. Reconnect ..............................
Move Service ........................
No. of Add. Meters .............. oe
� .
..............Z.��-
I10 7/61-500 PLUMBING INSPEC.T........
:......................