617 OT1�4.A
_ NO. ,i� STREE I 't{ � _ �.�O_• I
APPICATION FOR GAS PERMIT'
CITY'OF CUPERTINO t
n /
Dazle � t I: ftnln 195_ Permit No. E'J
1 r 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 `accordance with the provisions of the Plumbing Code of the City
of Cupertino, a l other-laws applicable thereto.
v ) r•
' Use of Premises
ugrz;=r—
Owne �4dd ss N(
Address ///�/ply/"��
COMA CTOR, AGE d 2.
Approve
qone--7I PL15MBING INSPECTOR
o Remarks (Check J) .
Type of Appliance I Units Fees II New Replace Relocate
Gas Ranges
'mall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces T
?Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit j � . II '-.71
Floor Furnace
Miscellaneous
NAME TYPE)
pp Iance Fees �� I
-;,Inspected and Approved _............ ......... ............... ............-........
.
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets I Size of Main
Gas Piping Fees
Tested and Approved . --9.- . �-
7ATE INSPECTOR