74730 1112 HoLLyhead Lane
CITY OF SAN JOSE 9 BUILDING DEPARTMENT
`��y�APPLICATION CFOR GAS PERMIT
''7
Date... l// e?—.-- --- . /-----... 19_�.L.. Permit No..C...9..2 ...........
The undersign�by m a I' ion to the P g Inspector of the City
of San Jose fora r a o gas pipes as listed on the
reverse side here a ees t nsta ai app lances and/or pipes in accordance
with the provisions of Article VIII, apte,[�4. of t e San Jose Municipal Code, and
other laws applicable thereto. / G ?'�j�lj v
certify that in the performs e or or whit this r it is issued I
shall not employ any person in any manner so as to violate the workmen's com-
pensation laws of Californi .
OWNER . .. cG'`� ...... .......... - - .
ADDRESS .... -----/ ...... ... ./7` v..���r:S ....
..
USE OF BUILDING
FORM 280-20 4/67 IOM Signed -.1�1-`7/2 =-"'`Y"." ..�..�.�. G!L/ ..............
1 1 1 9 ]4nl 1 vhPAd LainF� / �ur
Type of Appliance No. Remarks (Check V)
New Replace Relocate
Gas Ranges
Wall Heaters p/
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces -
Suspended Unit
Floor Furnace
Automatic Controls
Flue and/or Vent
Hood and/or Duct
Clo+hes er Dr
ig 5 �X
I
Permit Fee o�
TOTAL
FEE
Inspected and Approved 11,1`ef By
HOUSE GAS PIPING
Number of Oufletsi I Size of Main Z
FEE
Tested and Approved By