1099 / U _ P • F�l/1 - Lor NO.
a �
196% DATION FOR IGNSPERMIT
CITY-OF.CUPERTtNO-
Date Z� _ 195— Permit No.
M Fee $
M 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 in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto.
y
C
V
Use of Premises
in Owner e3t / '/-1Y-)"
I�/ Address '
B,, M- �Y),-r � Address
-6a nCONT8ACT08, AGEN7
Phone 1 G O " - _Z � .�APPr
PLUMBING INSPECT
Remarks (Check ✓)
Typed Appliance I Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers'
WarmingOvens
Percolators
Griddles
Steam Tables
Gravity)Furnaces II
�nded Unit
Floor Furnace
II
Miscellaneous _
(NAME. TYPE)
II
pp lance Fees Z
Inspected and Approved ....."........:... .".""..........................."..............
DATE INSPECTOR
'MOLISE GAS PIPING
Number of Outlets Size of Main
Gas Pipi* Fees
Tested and Approved_____--_ ��..... ... . .... .................................
DATE INSPECTOR