1096 (2) LOT NO. d1
�NO ACL Ell
FOR GAS PERMIT
K AUG 251960jgN
OF CUPERTINO
Dat a S 19560 Permit No.Ut
7 0 Fee$
Application is hereby made to the City of Cupertino for a permit to install gas pipes
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
of Cupertino, and all other laws applicable thereto.
a,
c
Use of Premises
�n Own •�-J-e,On O .LiJ-e--r- Address
L ByCID Address • .
/h CONTRACTOR, AGENT
`�. Phone f O Appro PLUMBING In IP OR
Remarks (Check ✓)
Type of Appliance I Units Fees I New j Replace j Relocatp
Gas Ranges
Will Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unitt
FloorFurnace
Miscellaneous
(NAME, TYPE)
pp lance Fees����—��
inspected and Approved ..............:... ...................;:..........................
.
DATE INSPECTOR
-,HOUSE GAS PIPING
Number of Outlets 7jl Size of Main
GaslPiping Fees /r •
Tested and Approved ... lq ....�.. ...............
ATB INSPECTOR