1561I LOT NO.
NO.
GAS PERMIT
RI4&agitcolt
AR 201UPERTINO
�Date CITY 0 Permit Fee $
a --sem-
ty 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
V of Cupertino, and all other laws applicable thereto.
u
e
Use of Premises /IE s /deNCIr
u
n n Owner_C6p&Aro,&A o0i70P4Rr1trs: Address
v�0 Lv� Address
CONTRACTOR, AGBNT 1
Phone _ _ _ r Approv
PLUMBING INSPE
Type of Appliance I Units Fees II
Remarks (Check V)
New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
-Percglators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace �
Miscellaneous
II
_=
(NAME TYPE) I I
II
pp Iance ees
—�—
Inspected and Approved ..............:...
...............................................
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of M in.L 1 y
Gas Piping Fees
—'-- r
Tested and Approved ... .. .�. b.
DAT INSPECTOR