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'+ COT NO Y I
N ® TRH 7
/ APPL T N FOR GAS PERMIT
2 1963 OF CUPERTINO
Dat � t� 3 Permit No.
3
CDR HI o
Fee S S
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
of Cupertino, and all other laws applicable thereto.
u
c
.� Use ofPremises—
Owner Address
By Address--5 o �� a
CONTRACTOR, AGENT
Q, Phone kf —3G /0 3 Approved
�J PLUMBING INSPECTOR
Remarks (Check J)
Type of Appliance I 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 Furnaces
Suspended Unit
Floor Furnace'
•Miscellaheous
NAME TYPE)
pp lance 1 ees
Inspected and Approved ..............:... ...............................................
DATE! INSPECTOR
HOUSE GAS PIPING
Number of Outlets Y Size of in /T
Gas Piping Fees
i Tested and Approved .... Z .1.7 .7 1 . .........................
T8 INSP8CT00.