608 (2) I 1w
" LOT NO.
'�. NO: _'R�HB '
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Y PPl1 CA TION FOR GAS PERMIT
y
CITY OF CUPERTINO .
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Date ^ - 195_ Permit,�Io.•(�
_
Fee S
is �yApplication,is.hereby.made to the City of Cupertino fora 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
Cupertino, and aIl;other laws applicable thereto.
Use of Premises
F
Owrier`, -
�n re
;iti By -4 ,
Address
�• CONTRA OR, AGEN 206011
�,(�,�j
Approved 206 ll
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.PLUMBING-INSPECTOR
Remarks (Check J)
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 1 II
Floor Furnace
Miscellaneous
NAME TYPE) II
pp lance Fees 11
Inspected and Approved ..............:_.I...................._......._-------------
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas�Piping FFees
,Tested.and Approved ... ... �. ... _..l..........................
oATe INSPECTOR