2493 LOT NO.-
NO.
O.NO. STREET
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ATION FOR GAS PERMIT
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W z ® D CITY OF CUPER_TINO
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O a Date � 193 Permit No. e521T!
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Ipp��ppTIpI(1 Fee $' �.sU
OCITY AgFicaf.LlIislhb}ebylmade 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
ZN and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all other laws applicable thereto.
Use of Premises
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3 Owner- �rjlltjL�ifIJ�� Address
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V_U PLUMBING 1NSPE.CC�OR
Remarks (Check J)
Type of Appliance 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 `
Miscellaneous _
(NAME. TYPE)
HOUSE GAS PIPING
t Number of Outlets � "'" Size of Main
',Gas Piping Fees b - j
Tested and Approved .i. . .w3! . .. ......................................
DAT INSPECTOR
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