2118 LOT NO.
((( NO. STREET
��1RPL ATION FOR GAS PERMIT
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P► GITY OF CUPERTINO
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3 < DEC117 1962 , 196— Permit No.
i Fee $_
n w � TQQ``pp ituliou'd�s �p}^ t' gY0 the City of Cupertino for a permit to install gas pipes
0 a 36� do g �Iapplia s l lEldbh the reverse side hereof, and agrees to install said pipes
im and/or appliances in accordance with the provisions of the Plumbing Code of the City
aw of Cupertino, and all other laws qpplicable thereto.
Use of Premise
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3 Owner Address
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— m Phon
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W a.
oState Licens I Approved
V CONTRACTOR. AGENT
Remarks ((-heck ✓)
Type of Appliance Units Fees II New Replace I Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters _
Blower Furnaces
Gas Fired Boilers _
Warming Ovens
Percolators _
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
N.liscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved ..,...�. ` ... . l.ca.�...........................
DATE INSPECTOR