2079 WE
&8
P _1C I/IT ON FOR GAS PERMIT
N
W z 16—
OF CUPERTINO
Z3UDat t1iPermit No.Fee A7
So
° i at is II�((����yy [ ��((��((��e City of Cupertino for a permit to install as pipes
'o a and abp¢anc�sl�f WJAIF reverse side hereof, and agrees to install said pipes
iw and or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and al her laws oplicable thereto.
nUse of Premise Z
> W
> N J'
3 Owner Address
o <
zrBZ Addressm.
Approved
CO TRACTOR. AG 'T
Remarks (Check ✓)
Type of Appliance Units Fees II New Replace Relocate
Gass Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
(NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved .... —2. .-......�... . ....................................
DATE INSPECTOR