2672 (2) LOT NO.
N ® POMC FOR GAS PERMIT
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z i CUPERTINO
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x ° 664
9964TT.IAN 10 19 4 �-
° a Date 196— Permit No.
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° App )afion is"Flerek QRFfbTL A'Vity 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
i m 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.
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Use of Premises
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r 3 Owner !>J.Q,c'� � !/F�s� Address
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° CO RACTOR, AGENT
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— 0 Phone20
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s State License /&46 Approved
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U PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees I New Replace 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
Nisce laneous
(NAME. TYPE)
HOUSE GAS PIPING
Number of Outlets I Z ,MoinGas Piping FeesTested and Approved ._... . ...........__.................
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