2812 V 7 Y / / I .�• LOT NO.
s; 0 RE
LCA A •ON FOR GAS PERMIT
°z Z TMAY 7 9904 C ICUPFRTINO
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Y °
3 'a Date Permit No.
a�i�-
UCITY OF } T— 6
i w Fee $ —
LL w Application is hereby made to the City of Cupertino for a permit to install gas pipes
° a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
'z N and/or appliances in accordance with the provisions of the Plumbing Code of the City
< of Cupertino,Aallotws applicablethereto.
'rj w Use of Premi00Owner Address
ZJoB tE rr Address
3 _
— m Phone
vz
p o State icens Approved `
/7 —U ` • 1 KWAMN
Remarks (Check J)
Type of Appliance Units Fees II New Replace I Relocate
Gas Ranges
Wall Heaters
as Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
uspen a Unit _
Floor Furnace
Miscellaneous
(NAME TYPG)
HOUSE GAS PIPING
Number of OutletsI Size of Main
Gas Piping Fees
Tested and Approved ........................I................................................
DATE INSPECTOR
Multi-House Gas Inspection Card
Gas Permit No. ....................................
GAS PIPING APPLIANCE FURNACE
., APT. TESTED AND INSPECTED AND INSPECTED AND
NO. APPROVED APPROVED APPROVED
1.
' 2' 7 -411l
3•
5.
6.
7.
8.
9.
O
11.
L2.
13.
14.
15.
16.
17.
is.
19.
20.
z1.
22.
23.
24
25.
118 1/63-500