1167 (2) T �
LOT NO.
Ap+lT ; . v _
= APPLIC , , ON FOR GAS PERMIT
CITY OF CUPERTINO
Date__L -it Y 195L o Permit No.
y ,
Fee $
.A
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.
q U
Use of Premises
i Owner�di: �r2 J" �� Address
yy T p
By'.' ,; ��r wt�� ( A Address t0l0kri,, uCc.c Lf
i'. CONTRACTOR, AGENT
Approved
i2-13 Phonet "�'�' /90r� PP
i PLUMBING INSPECTOR
Remarks (Check d)
Ty ' of Appliance ;I Units Fees II New Replace Relocate
Gas Wges ":I�h, I a: II
Wall''Heaters .• �+� , II I I _
GassPlates I si
Circulating Heaters
Blower Furnaces
Ga:Fired Boilers I SIA .11
Wainiing Ovens
Percolators
Griddles t ?IIS is r, I
tiles I
Gfa'a 1 `aces
r,. naa a I. _
+ire (Air
I II
Misce115oeo`us
(EAAA TYPE)
• s, I I II .° I I
c I .
'• I I II�� I I _
�" " I I II• I I
pp Iance Fees
Inspected and Approved ............. _.j.............................-------...........
DATE INSPECTOR
HOUSE GAS PIPING
*Number of Outlets - j Size of Main I _
Gas Piping Fees ; le
_P g I
Teste: and Approved -cg .....................
DATE INSPECTOR
E I p P- 7 1.
GASB SERVi' ICE OFFICE
s BDILDING INS OFFICE
CITY OF�.0 INO'
.............................�... . . -_....... .... • 196.. .
To
You are hereby authorized to conned the GAS service for
Owner or Tenant .�j (i1/LLf? i... L9�J� LS!L;!.. -- ..-'__...........
..� •' 4
? rf
�. -New Service •
... f'Meters ........----------- ---- -.. ��. Reconnect ..............................
Move Service ---------------.......-
No. of Add. Meters .............. Move Meter -------------------------.
�.
.--...----- -.- -..--------------......
LUMBING INSPECTOR`.
'�.6y 'to 1160-560