2452 1035'6 / L'prrlQ LOT NO. (Q�
NO. STREET
APPLICATION FOR GAS. PERMIT
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W 2, 'L CITY OF CUPERTINO•`
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3 U !F1N4 . .y�ya . „� 1963 Permit No.
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o Application
. LL QApPlication.isheb :..madeti to the Cit of Cupertino fora permit to install as pipesesw ^f"% : K ,.enro
O an /or'gas-appliances r
as lutedon the reverse side.hereof, and agrees to install said pipes `
'z,m and/or appliances in accordance with the provisions-of tie Plumbing Code of the City
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of Cupertino,and all other laws applicable theret6+ _
< Use of Premises
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'..- r3 .Owner Address
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UORTRACTOR..AGEN r4
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'. c�r�s S Apprme
"PLRVIN IN$ EMR �'HI
Remarks (Check ✓1
Type of Appliance Units Fees I New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens '
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspende Unit
Floor Furnace
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Miscellaneous "-"•
(NAME. TYPII) -
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HOUSE GAS PIPING
Number of Outlets Z Size of Main
Gas Piping Fees •SU 7
Tested and Approved ..(.tl.r.. ..d�..._ .... ...................... ..........
DATE
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