1972 LOT NO. _
NO. STREET
® aTIO
I N FOR GAS PERMIT
' OF CUPERTINO
Date 'AUC 8 x,11 , 195_ Permit No. Qf� -
CITY OF CUPERTINO Fee $
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.
u
• � Use of Premises
a' v
inn Owner - Address_�Das
By Address
CONTRACJ%R, AGENT .�
Phone %Approved; = -
'� 1 q um BING''INSPECTOR
RemlrkspCheck ✓) .._
Type of Appliance 'Fees Fees New Replace Relocate
Gas Ranges
Walt Heaters I 11
Gas.Plates I II
Circulating Heaters JI
Blower Furnaces
Gas Fired Boilers
Warming Ovens I
Percolators
Griddles I I I
Steam Tables•
Gravity Furnaces
Suspended Unit •+
Floor Furnace ' I
Miscellaneous I I _ II
(NAME TYPO I '
it I I _
-
II
s-
pp 1 nce Fees
Inspected and Approved,.........q.,..;...L................................... �1....
" DATE INSPECTOR ,«
HOUSE GAS PIPING
Number of Outlets • I Size of in
Gas Piping'Fees I TJ
Tested and Approved
DA NSPE O
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