1947/ V f I J -z' •,1 Imo. LOT NO.
NO. STREET _
W
r; 7P (CATION FOR GAS PERMIT
ITY OF CUPERTINO
eaeq195_ Permit No.
CITY Or CUPERTINO 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, aid! otherlawsap Icable thereto.
Use of Prewises
u 1,
a
N
Own ef Address-
By
By �_' AddressW
_ CONTRACTOR, AGENTi
' Phone X i ®� 2 : i r/� ' L.ApproveIdAUMBING INSPECTOR
Type of Appliance I Units Fees II
Remarks (Check J),,
New Replace �. Relocate
Gas Ranges
Wall Heaters ��
I `• �.. ,
Gas Plates
1 X
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Perco�utors
Griddles,
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
Appliance Fees
Inspected and Approved ..... __....:...L....__ ....................._....
nATF INSPECTOR
HOUSE GAS PIPING
Tested and Approved ...
I, the'undersigned.do..hereby certify that
I am the owner and occuppant f he single -
family dwelling at
forj ich I am making app io ion ;to 0
LL) also cer iwork as a homeowner.
- at I will not hire any
non-license r contractor,
but will do this work myse f.
h RHO( ?yf
JMHKH SIUNATURE