2139 LOT"NO. /
%1—r. _-•. -NO. � eE J
A�r
ft6*A N FOR GAS PERMIT
x f�AP1t `?353 C -,toF CUPERTINO r
Date. t97z-3 Permit NO. t'
Ir CIS! IN
Fee S 7
Application is hereby made to the City of Cupert no"for a peimit'to install-gas pipes-,-
and/or
ipes ` }
and/or gas appliances as listed on the reverse"side'hereof, and agrees,to install said pipes
' and/or:appliances in accordance with the.piovisio f, a Plumbing Code of the City
of Cupertino, and all oth laws applitable thereto. j
'i.5 w - t .• in. ~ 'rti G .
Use of Piemises4 -
G 2,'x
�0 3.',^" ' ..:..:.Sir'"' .- -•.- .-'a _r:.+n.F,.-
,�e[ri Address
Address -
CONTRACTOR, AGENT -,ls
I Phone "_�:� <'r�_.! Approve
PLUMaI G MSPECTO
1
Remarks (Check ✓1
Type of Appliance I Units Fees II New Replace Relocate #,
Gas Ranges
Wall HeatersI I "'?':��� ,., 4,. I'•,.•7 a i e;'}' 1{r
Gas Plates :~
Circulating Heaters �2,'': ,'�f�• !xt.
Blower Furnaces '
Gas Fired Boilers
Warming Ovens
Percolators I
Griddles I I I I
Steam Tables �
Gravity Furnaces l
�Suspen—' ded Unit
Floor Furnace II
' Miscellaneous it
NAME TYPE) i I III—
I
I I II I
I
PP lance Fees r
Inspected and Approved .. .:....:.:aP,td: .::.t :!:::...Rr!.......r:w.. '
DATE_ ,�. tN9PPCTOAi% .
HOUSE
Number of Outlets I I Size of Main I .f
Gas Piping Fees I _Y
.....................
INSPECTOR
DATE INSPECTOR
y ' Q -q
FL w
09
Gym
O
� � m
r '
R 1 OO -1
�i 40
� rt n ❑
r, o
� n