609LOT NO.IA: =/ .
NO. ' SIR W'� -`
ry� aA PLICATION , SPERMIT
CITl iOF' ERtA
(� Dater• - r - - -=h `y 195= Permit No.
Fee$.
. .. 4 W
Application is herebymadE'4ito.the_' `f'Guper[ino.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.
v
Use of jP,,remises I�
Cn Owner= j "�'� esd�ss
"Y
(Byr t - AW Address
CONTRA OR, AG T /
Phone f
1- Approved„
PLUMBING INSPECTOR
z;=s.
T.ypeof'Appliance I
Units Fees I
Remarks (Check ✓)
New Replace Relocate
Gas.Rariges
all Heaters
l
_N
Gas Plates
Circulating Heaters
Blower Furnaces
Qy, Fi ed .Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous.�,
NAME TYPE), �I
pp lance Fees
JI I
Inspected and Approved--------- ....:...��.
_ - DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Idain
Gas Piping Fees -f
—�--
Tested and Approved .../1�f9...�... <�........................
)A E INSPECTOR