1890 LOT NO.
NO: STRERT ,
IF,
NFOR 'GAS PERMIT
�' ® OF CUPERTINO
1 � /DateJUL 2,;19V)4' 19" Permit No. �U �
CITY OF. CIDP€RTINO I 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
t: and/or appliances in accordance with the provisions of the Plumbing Code of the City
-J of Cupertino, and ill other laws applicable thereto.
Use of Premises
:a
Ii Owner Address
By� � � Address/
CONTRACTOR, AGF,NT
Phone_OW,2— 3-4/7 7 TApproved
PL UMeING INSPE
,R ack (CheckJl
Type of Appliance I Units Fees II New Replaced.Relocate
Gas Ranges
Wall Heaters I I
Gas Plates
Circulating Heaters I 1 II
Blower Furnaces 11 I
Gas Fired Boilers 1 I I I N
Warming Ovens ^
Percolators
Griddles
Steam Tables 1 II
Gravity Furnaces 1 1 Il
Suspended Unit I 1 t II� '
Floor Furnace '1 j I I N
Miscellaneous
NAME TYPE) 1 1
I I II1 , I I
I I II I I
pp lance Fees 1
Inspected and Approved ....... ....:_.I.......... ..................... ..............
DATE INSPECTOR
HOUSE GAS PIPING
IMain..
Number of Outlets '0, Size of . .
GasPiping Fees
_3
Tested and Approved .. . .02�.Z....1....... . .................. ....... .......
DATE INSPECTOR