2813 (2) as - � ^ '-
OT NO.
n EE
C A ON FOR GAS PERMIT
W z TMAY 7 19Va C OF CUPERTINO
sp
y O
l3V Date T � ,l�{i Permit No.
Fee $r13
00
4 w Application is hereby made to the City of Cupertino for a permit to install gas pipes
O a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
is and/or appliances in accordance with Ithe prov'sions of the Plumbing Code of the City .
a w of Cupertino, and all other law applicable t eto.
w I
t �
a Use of Premises
00
3 Owner Address
oa
2J t
o By Address
3 F CONTRACTOR, EN
— w Phone — s
W z
oState License Approved
� t PLUMBING INSPECTOR
NewReplace
cc ✓1
Type of Appliance Units Fees w Re placlace Relocate
Gigs Ranges
Wall Heaters
Gas Plates
iculating'Heaters _
Blower Furnaces _
Gas Fired Boilers
Warming Ovens
Percolators _
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
j HOUSE GAS PIPING
Number of OutletsAS17, F Main
s.Gas Piping Fees .oTested and Approved ... .....�. . .................
TE ltolr INSPECTOR
Multi-House Gas Inspection Card
Gas Permit No. ..............-....................
GAS PJAND
APPLIANCE FURNACE
APT. TESTEDINSPECTEDAND INSPECTED•ND
NO. APPROP D APPROVED
4.
5.
H.
9.
lo.
�1.
I'2.
13.
14.
15.
16.
17.
1 H
9.
_1.
22.
23:
24.
25,
118 1/63-500