2214 LOT NO. 'H
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�A LiCATI N .FOR GAS PERMIT
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XIYIM��AR 2 9196fO a Date �/ /� ❑ �9�6-3 Permit No.
3 C� 1 OF CUPW 'C�� Fee $ e:�W4�1
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
a w of Cupertino, and all other laws applicable thereto.
Use of Premises
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CIO AGENT
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oStale License Sf Approved
PLURE MBING INSPECTOR
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Remarks (Check J)
Type of Appliance Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters J
Blowe F ces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
'Floor Furnace
Miscella eous
(NAME TYPE)
HOUSE GAS PIPING
Number of Outlets / Z/ Size of Main
Gas Piping Fees
Tested and Approved ._(l ..%i.Z.. ..�.� .. �.`............._...............
INSPECTOR
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