865 - 07'16 LOT NO. 89 ' ♦.
NO. + ST EHT
APPLICATION FOR GAS PERMIT
-CITY,OF CUPERTINO
Date 195_ Permit No.-
Fee
o.Fee $ i 5Z7
Application ishereby made to the City of Cupertino fora permit to install gas pipes
and/or gas appliances askisted-ori 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.
Use of Premises
u �p
in OwnerAddress -&/1 t . k
By I Address
HEAfWa$c�AVE., C0• Approved WILT IAMn-'HENEVICH
Phone + PLUMBING INSPECI00.
• 1 {� ,Remarks (Check %7)
Type,of,.Appliance. ",hits, a 11 ;New Replace Relocate
Gas-'.Ranges ny i1•r 11 _
Wall Heaters ,j� { i� �I;A'V.;
-(3as Plites _ '�'.
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens.+
Percolators F, F
Griddles T I 11
Steam Tables ! ��
Gravity Furnaces 1
Suspen`ded„Unitu II
Floor Furnace
Miscellaneous
(NAME TYPE)
pp lance Fees •SU
Inspected and Approved �� /j l<d.'... . . L. ...-......- .........,
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets;.. Size of Main
Gas Piping Fees _':;',{
Tes!-ed and Approved ........................{..............................................
DATE INSPECTOR a
t 1�
j r.'