1286 95- ��1i LOT NO. y
NO. /
APPLI i FOR GAS PERMIT
1
IMAR 1 1� CUPERTINO
Date I��i Permit No.till , VF
O�
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, and all other laws applicable thereto.
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Use of Premises ( Qice
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Owner . m 'Address
W .ldAddress �. .s _ P�Ct�r
CONTRACTOR, AGENT
- +~
y Phone QX ' O-� %9 e E `Approved �f
PLUMBING INSPECTOR
Remarks (Check ✓) .
Type of Appliance I Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circod. ng Heaters
Blowei Furnaces
Gas Fired Boilers
Warming Ovens
i Percolators
Griddles
Steam Tables
Gravity Furnaces-
Suspended Unit II
Floor Furnace
Miscellaneous
(i`IAME TYPE) II
III I I _
pp lance Fees
Inspected and Approved ..............:_. ......... ...............................
......
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets 7✓ Size of Main _
Gas Piping Fees �}.� �� .•
—te—
Tested and Approved 3loL�.-_ .. -"
7A E
INSPECTOR
TOR