2142 LOT NO.
NO.
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APPLICAT�IONFOR GAS PERMIT
AN 7 1963T)L& CUPERTINO
Date_rITY `�IDf'pTPermit No'.-
Fee
o. ��C I
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
1 \ and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all er laws applicable thereto.
c
-'r' - Use of Premi
Cn Ownerll` '.r. E!,Ct— to+. ;fn Address f
II gyf� !
'._ Address
CONTRACTOR, AGENT
Phone �/r%a— <P--c? `.� Y
-" Pproved
PLUMBING SPE
Remarks (Check ✓)
Type of Appliance I Units Fees II New I Replace I Relocate
Gas Ranges II 1 I w
\/all Heaters I I I I
Gas Plates
I I II I
Circulating Heaters I I 11 I I
Blower Furnaces I II I I —
Gas Fired Boilecs I .:^•�`=�1 .•�— ii
Warming Ovens
Percolators
Griddles I I I I
Steam Tables I 11
Gravity Furnaces
Suspended Unit II
Floor Furnace I
Miscellaneous
(NAME TYPE 'I, , •;�� ,4� '"I"''
I I �I � • -• • I I _ '
PP lance 1 ees I I II I yl w
Inspected and Approved ..................L....._..........................:::.:..
DATE. INSPECTOR q"71r
HOUSE GAS PIPING t
Number of Outlets I COL I Size of Main
Gas Piping Fees w O
—�— —
Tested and Approved ._' ...- .-` ...L ... A,.
DATE INSPECTOR w..
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