2615 LOT NO.
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IU APP f L(I,.�'O� N FOR GAS PERMIT
w z NOV 5 '963 .iOF CUPERTINO
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3 < Date. �ti+ ��� 6 Permit No.
i Fee $ 151,
O 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
im and/or appliances in accordance with the provisions of the Plumbing Code of the City
w of Cupertino, and all other laws applicable thereto.
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Use of Premises i��. ./1-•��/;
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oa Owner —r,��r�+�r.r��1i����n�-,,�.a� Address
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-3 < CONTRA OR, AGENT
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oState License I Approved
yl -U T111PLUMBING 1XSPECTT0j
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Remarks (Check J)
Type of Appliance Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
*as Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
'Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
?Tscelinneous
(NAME. TYPi1)
HOUSE GAS PIPING
Number of Outlets of in
ryas Piping Fees
Tested and Approved ..........................
AT INSPECTOR
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