2143 (2) •y 7S3 % �r�/". LOT NO.
NO. STRE T
VJAND '
'CTION FOR GAS PERMIT
j OF CUPERTINO
7 ?353 /�
Date 3 19� Permit No. al T�
CITY Or CI TER-Tlf!!Q ;.::.K.: Fee $
.,, A45--t-
Application 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
;.r;add/or appliances in accordance with the provisions of the Plumbing Code of the City
.e
1.4; a..•of.Cupertino, and all other laws applicable thereto.
.a -,�UseofPremises ?'
y,..
W) OwnerLU. � / Address
s.•,:gyf _ //�!� �� � Address^.. C°✓..I`.-.�1"
CONTRACTOR, AGENT t
Phone-//---f?_ 9— ? ei 9 7 \ Approved `
PLUMBING INSPECT
{I
Remarks (Check d) q
Type of Appliance I Units Fees II New I Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates I it
Circulating Heaters I li
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles I _
Steam Tabl I it T 1
,Gra�jTy Furnac li I I 1'
,i
„��endea Un• I I ii I _ ��
.Floor Furnace I li
Miscellaneous I ii
NAME TYPE)
u
I i li
i 1
pp lance Fees ���
Inspected and Approved ..............:...!. ......................
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets I Size of Main
Gas Piping Fees
Tested and Approved ... .4!?...1..i......2 ....................
DATE INSPECTOR
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