1483 LOT NO. / -
NO. STREET '
® o 1F195
FOR GAS PERMIT�+T�+ 2 1OF CUPERTINO
Da e �04/ '� �'" � Permit No. �
4-
' CITY 0 CUPkRTINO Fee
Application is here y masa to the City of Cupertino for.a permit to install gas pipes''
b'J and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
,
vq and/or appliances in accordance with the provisions of the Plumbing Codeof the City'
of Cupertino, and all other laws applicable thereto.
y 'g
v 11
a Use of Premises ( ^ i ,v
N ` T. ._ -
in Own / '�tr�C_t/1//lMv Address
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Address vi
CONTRACTOA AGENT
pprove*tk 2�
PLUMBING INSPECT
__ ll
Remaiks (Check ✓) '
Type of Appliance I Units Fees II New
Replace Relocate
Gas Ranges 11 1
Wall:le-aters
Gas Plates
Circulating Heaters
Blower'Furnaces
Gas Fired Boilers
Warming—OesI I ��-
Percolators
Griddles
Steam—TablesI I
Gravity Furnaces
Suspended Unit j
Floor Furnace 11 L
Miscellaneous
NAME TYPE) I I I
. II II III
pp lance Fees ti�
Inspected and Approved ---------...;.:_.L..__....__..._...... .....
......,.(._...
DATE INSPECTOR '
HOUSE GAS"PIPING: ,
Number of Outlets I 1 1 Size of Main--3% —
Gas PiAng Fees
_3
Tested and Approved ..,� LL.. - -- "'
DATE INSPECTOR