1113 ��I \'/ (.✓/,{i[i(�'ly �/11A.Ti'li�+ LOT NO.
NO. STREET
® AV IA qN FOR GAS PERMIT ~
�`+ C OF CUPERTINO
Date O" r ¢ � O
19 C) Permit No. /
CITY OF CUPERTINO Fees
Application is hereby made to the City of Cupertino for a permit to install gas pipes
VO and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
Vo and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto.
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Use of Premises �'G 5 t C Al C c=
h Owner
O, l/LL) Ety - Address
By St V t 1/.o AIMk Address "/I A C
�. CONTRACTOR, AGENT
t o Phone A k" ' % D Appr
PLUMBING INSPE
Remarks (Check ✓)
Type of Appliance I Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circylating Heaters
Blower Furnaces
Gag Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit ( II
Floor Furnace
Miscellaneous
NAME TYPE) I -�
pp lance ees
fnspected and Approved .............. ................................................
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets 2 Size of Main
Gas Piping Fees
Testedand Approved ........................ .........................................
DATE INSPECTOR