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® APPLICA 1 FOR GAS PERMIT
6 19620 F CUPERTINO
Date 01 Permit No.CIIY
1��3
c� Fee $ d�
Application is hereby made to the City of Cupertino fora permit to install gas pipes
and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
hl and/or appliances in accordance with the provisions of the Plumbing Code of the City
Cl of Cupertino, and all other laws applicable thereto.
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Use of Premises
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X n ��Ownet "C01
Address
_IAddress
Phone Approve
PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance I Units Fees II New Replace I Relocate
Gas Ranges
Wall Heaters �
Gas'Plates I �I
Circulating Heaters
Blower Furnaces I II
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables I I IIS I� I
Gravity Furnaces I
Suspended Unit—j
Floor Furnace 1I
I I II I
Miscellaneous
(NAMIi TYPE) I II
II II II II II -
I I II I
ppLance ees _
Inspected and Approved ..............:. I...............................................
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets I I Size of Main
Gas Piping Fees .2, 00
—1_._
Tested and Approved .... . . ..-�...1.... ..............................
TE tNSPBCT00.