800 L07 No.
STREET
A,,"P{{,P�t%TION. FORGAS PERMIT
1TYOF CUPERTINO
toQCT 22 179 195_ Permit No.
C11PERTINO 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 accoidancee--with the provisions of the Plumbing Code of the..City
of Cupertino, and all other-laws applicable thereto.
v
Use of Premises
a -
_v
0 Owne d Address
j By C Address
c e Ta , ncENr i WILLIAM D. BENEVI H
Phone Approved
�. PLUMBING INSPECTOR
.. Remarks (Check J) _
Type of Apliliance I Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas-Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables I ��
Gravity Furnaces
• Suspended Unit
Floor Furnace i 1 11
Miscellaneous
NAME TYPE) I II
pp Mance Fees
Inspected and Approved ------- --- .............. ...............................
..
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlet-s-1 I Size of Main
Gas Pg Fees
—s— —
Tested and Approved ..s. - .4 ...Iy .. ......�............................
DATE d( INSPECTOR