1650 /O�HD /iici/fBa�` Dnivr LO, NO. �-
'� NO. STREET
D1 R GAS PERMIT
ear UPERTINO
Date P�`i �-�Jf 19 —Z Permit No. `
00
a CITY OF. CUPERTINO Fees —
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
and/or appliances in accordance with the provisions of the Plumbing Code of the City
V of Cupertino, and all other laws applicable thereto.
a,
Use of Premises
:a /r f SiOG NG r'
u
m
rn Owner CuF[r/l ri.v O.PnArit Tirs Address 62,0 " 7' "u c,Itii'
By R,96pk '0211MAFIAlgr Address C y L
CONTRACTOR, AGENT I
Phone 7 – t Approve
PLOMHING INSPECTOR
Remarks (Check ✓)
Type of Appliance I Units Fees II New Replace I Relocate
Gas-R
\�/d Heaters
Gas laces
I I II I I
Circulating Heaters I I II I I
Blower Furnaces I I 1
Gas Fired Boilers I 1
Warming Ovens 1
Percolators _
Griddles
Steam Tables I 11
Gravity Furnaces I I_
Suspended Unit
Floor Furnace 1
II I
Miscellaneous I 1 ail -
(NAME TYPE) 1 I I
11 11 111 II 11 _
pp lance Fees
Inspected and Approved ..............:...1................................................
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets I I Size of Main I�
Gas Piping Fees 12, o
Tested and Approved .. . ..OATS
1..... ........................
INSPRCTO0.