2303 • LOT NO. ter'
NO. STa T
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A�TION FOR GAS PERMIT
OF CUPERTINO
zM MAY 2 91963
o
0 ¢ Date 196— Permit No.
° ]' iyatibH is hYW4n`eNF jto`tthe 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
00
W ��i
sOwneroaAddres
z B /L Address /d /e o !yo—
O CONTRACTOR,—AGENT
3 N ��� /—/8za
a � 7
State Licens 6 751 Approved \
PLUMBING INSPECTOR
Remarks (Check ✓1
I Type of Appliance Units Fees II New Replace I 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 f
'Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size o Main
Gas Piping Fees
Tested and Approve .........
DATA
IN PU70R
i
Multi-House Gas Inspection Card
Gas Permit No. ....................................
GAS PIPING APPLIANCE FURNACE
APT. TESTED AND INSPECTED AND INSPECTED AND
NO. APPROVED APPROVED APPROVED
2.
3.
4.
'5.
6.
7.
8
9.
10. _
11.
1.2.
13.
14.
1.5.
76.
17.
18.
79.
20.
21.
22.
23.
Y4.
25.
118 1/63-500