804 -
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PLICATION FOR GAS PERMIT
1CI,TY FCUPERTINO-
Date 1RT
HH 1 ' � nrt �flCf r/ .
J � Permit No. ,(�e
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�7 hn Fee $
Application/is hWCebyrm�ajl.-�ffij ,tlty')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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V �
I � Use of Premises
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!' -gin Owne dress _
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By Address
{ l c A nGENr �1/ILLIAM D: SENEVICH
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Phone--V�� Approve >
I� PLUMBING I'N$PECTOB
Remarks (Check ✓) -
Type of Appliance I Units Fees II New Replace Relocate
Gas Ranges I1
Wall Heaters--"`"`—'F 1 11 1 1 I
Gas Plates.
Circul 'i— eaters
Blower aces
Gas a Boilers
Warming Ovens I I
,Rercolators—11
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous it
NAME TYPE)
pp Iance Fees �� f
::Inspected and Approved -------- ----- ...............................................
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets j l Size of Main
Gas Piping Fees ,5 . "���
— (--
Tested and Approved
DATE INSPECTOR