2119 LOT NO.
NOf1A
El
� ION FOR GAS PERMIT
OF CUPERTINO
1962 Y 0
LL
/
30 a Date 196_ Permit No.
LL CITY 0£ CUpEN Fee S—
N� i
0 Application is hereby n elfo the City of Cupertino for a permit to install gas pipes
`o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
is and/or appliances in accordance with the provisions of the Plumbing Code of the City
a W of Cupertino, and all other laws licable thereto.
F sls3
Use of Ptemises
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oa Owner ^_ Address �fa-Gy/�P p
j z By �-/ , �A'J ��f , Address_4 e3l
Z Phon 1
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Approved,Licens QS o
CONTRACTOR, AGENT
_V
Remarks (Check sr)
Type of Appliance Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers _
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Fusnacts
Suspended Unit
Floor Furnace 1 11
Miscellaneous
(NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees a
Tested and Approved ` ✓e��......
DATE INSPECTOa