905 (2) ( 0 _
J, /t,l� / l LOT NO. _�
'J71 F" �'NE:
STREET
rt�
i
0"JAN
a-APPUQATION FOR GAS PERMIT
CPFY OF CUPERTINO
201960 � ds�
Date , 195_ Permit No.
( CITY U CUPERTINO - Fee $ / s=ue
} \ 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.
Use of Premises
F
a,
J5 Owner Address
y By Address
I ONTRACTOR, AGR r Approved WILLIAM D. BENEVICH
,.
Iq Phone PLUMBING INSPECTOR
rmRemarks (Check V)
>Typq of Appliance I
Units F�' SXI
..New I Replace I Relocate
'Gas:Ranges 1 11 111
Wall Heaters V11
.Gas Mates
Circulating Heaters'
Blower Furnaces•
Gas Fired Boilers,
'Warining.9yens I 1 11
Percolators
Griddles' *
Steam—Tables
Gravify Furnaces
Suspended Unit.
Floor Furnace II I k
JI
Miscellaneous
(NAME TYPE) I II
Appliance Fees
Inspected and Approved -------- ----- -- ---- -- - -----------L-....
DATFINSPECTOR
HOUSE GAS PIPING
-W-utilber of Outlets
—
—�- 1,I
2 _Size
ize of Main
Gas Piping Fees�
Tested and Approved -. .
....". . .4..r
.—...—
. .......
DATE