799 / II 1099 U' :f a T t` LOT NO.� -
4i, 'NOv.• STRBBT `. '� ', -
v +APP`L G1 • It-FOR 'GAS PERMIT
D� 1 "C O CUPERTINO
Date 10 l 22 W{�d; Permit No. ,
IV iii COWIN 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 iti accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all-other laws applicable thereto.
:a
Use of Premises
Own _�/ Address
s By Address
A^ C A R, AGENT
'n Phone ApprovewILL1AM D. BENEVICH
PLUMBING INSPECTOR
1
f
Remarks (Check ✓)
Type of Appliance I Units Fees I New Replace Relocate
Gas Ranges
Wall Heaters
—Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers I
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces —
Suspended Unit
Floor Furnace
Miscellaneous jj I
NAME TYPE)
pp lance Fees �I f
Inspected and Approved ..............:... ...._..__......................... ... .....
DAT F, INSPECTOR
:r HOUSE GAS PIPING
-:Number of Outlets Size of Main %g
Gas Piping Fees
—"—ested —
Tand A roved ..�.a.� .� - --� '� ..............
FF DA E INSPECTOR