2525 LOT NO. ✓r
(� NO=CIL"ATION
ST EET
FOR GAS PERMIT
CITY OF CUPERTINO
° < r 1963 Permit No. asps
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F ° "!THpptic�ation'is he'FNtiyT rt r
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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v. Use of Premises .Q A l l r ofYl_.l`0,
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oa Owner p 0ClrnC[ Address Cf/Q6WV0
o Bye` Address esa-f"Q52Dr,_._,p
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a State Licenser Approved
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Remarks (Check ✓)
Type of Appliance Units Fees I New Replace Relocate
Gas Rang=Boilers
Wall Hea
Gas Plate
Circulatin
Blower F
Gas FiredWarmingPercolator
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace q*M'SCeItare'us
NAME TYPE
HOUSE GAS PIPING
Number of Outlets Size of Main 7r v
Gas Piping Fees
Tested and Approved &-,-- -T-0-R................INSPEC