1455 /C/7 O/ • Lr'1'�` ���=C C..�( LOT NO.
NO. STREET
TION FOR 'GAS PERMIT
CUPERTINO
'• ' Date ® Permit No.
'
. Fee
-.�Apg c r i Creb�j tttoit= -insall^gas.pipes
-t( ind/oi-
as appliances arlisfed on the reverse side hereof, and agrees to install said pipes
. .,;and'/orlapoliances,in accordancerwith the provisions+of the Plumbing Coderof the City .
-,, o to 1" �x
of.Cupertino,'and'all.other lawsapplicable thereto.
Use of Premises
Owner' POLY /v00yES�^�•Address`�`3� iou
d-:
LvIC�'C�t - Toly �S Address
/7 CONTRACTOR, AGENT,
phone L /. p 4 O A�SProved `
QV, %
"Remarks-(Check J)n
Type of Appliance Units Fees I New- I'Replace l Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces �t. ":r ".,.,:�;. , �!. , :4
Gas Fired Boilers gill?:iiC<.*: .�w;r;;r': :y ;t.'ES"•
Warming Ovens - •""�_`'-�_`'`+''' +
Percolators
Griddles "4;.utr•s.; i �; .t:an �.
Steam,Tables
Gravity'Furnaces ,,rsv r�I '+ a'>' h+•+
Suspended Unit
Floor Furnace
Miscellaneous t_.,�� 5?��s.,•�-)r",�i�?,mrir+S.�r• s '!• i
NAME TYPE
Appliance Pecs
Inspected and Approved .._. ...... ._..__........................-4Q6
DATE INSPECTOR
HOUSE GAS PIPING.. .
Number of Outlets -1, / I Size.of Main
Gas Piping Fees ,�/•p - /
Tested and Approved.: ..
-S DATE'