1640 LOT NO 3
NO. < "" STREET
lr� ,�MPIT#ZJON FOR GASPERMIT
ApD 1OF CUPERTINO !/Date APR li/ /L_ ., 19 .2 Permit No. To
s CITY OF CUPERTINO Fee $
Application is hereby made to the City of Cupertino for a permit to install gas pipes
I 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
�1 of Cupertino, and all other laws applicable thereto.
0
Use of Premises
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m
in Owner Z'ZAe'Ro Address
B � / d
` y CONTRACTOFNAGENT I I Address
` hone Approved
l PLUMBING INSPECTOR
Remarks (Check ✓) 1
Type of Appliance I Units Fees II New Replace Relocate 1
Gas .Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens 11
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit II
Floor Furnace
Miscellaneous
(NAME TYPE)
pp Iance ees
inspected and and Approved ..................L..............................................
.
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets 'I Size of ai 7 y
Gas Piping Fees . 6
Tested and Approved .. . .6�. .. ..••
DA E NSPE R
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