522 /OssTJ/ V 4-. 4/ A'xe LOT NO
NO. STREET
P TFOR GAS PERMI
(� FRTINO"
w '1
Date �JU '`3• 1J`495 Permit No. --
" c� 1
� QF4�P �T��t4 Fee s /'
\ Applicatio 1 here ma o t upertino fora permit to install gas pipes
1_ and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
V) and/or appliances in accordance with the provisions of the Plumbing Code of the City,
of Cupertino, and all other laws applicable thereto.
y
u
a Use of Premises
/,37 �
_ � A
GO Owner ��.�-/-•,-�� �/ � Address
gyd_I I- lc— cnwjo INC Address
Phone P. CFO IMQc{�"GkLN"r Approved
\ • • PLUMBING INSPECTOR
Remarks (Che )
Type of Appliance Units Fees ck %7)I New Replace I Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolator's_ I I
Griddles -
Steam Tables
Gravity Furnaces -
Suspended Unit I I II
Floor Furnace
I I II I
Miuellaneous I I iI
(NAME TYPE)
I I II I I
I I II I I
' I I II I II
I 1 II I 1
pp lance Fees I 1 11 1 1'
Inspected and Approved -----.........:...L..._._...._................................
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets I I Size of Main
Gas Piping Fees I
Tested and Approved /� ./+�./..9..I ... .. ...
DA E INSPECTOR