2617 ggi�n/ LOT NO. 3�
FINIOV5
® sTRt�ktC TIQN FOR GAS PERMIT
Wi tlJ ' OF CUPERTINO
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1963 °'
0 a Date n Sa ' 4 196— Permit No. 2 6 /
CITY Of CUPERTII CFees 3:c�
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
and/or appliances in accordance with the provisions of the Plumbing Code of the City
is
a of Cupertino, and all other l applicable thereto.
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Use of Premises
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3 Owner Address
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09TRACTOR,AGENT
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— m Phone C 7 S j Z 3
oState License Z Approved
U PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees II New Replace Relocate
Gas Ranges
RUall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables _
Gravity Furnaces
Suspen e�Unit
Floor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of OutletsSize of Main
j Gas Piping Fees_ 0'
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