2141 (2) �3 LOT NO. I9
NO.'4_'.'+R SI0.EET
�M I pN;� FOR GAS PERMIT
+ ' q C LOF CUPERTINO
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Permit No '� �` �.s
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ICI-TY-:�F�_CUPERTfiQ
Application is hereby made to the Citybf Cupertino fof a pe"fmrt to,install gas pipes'.
and/or-gas appliances as listed.on the reverse side-hereoCind agrees-to insihll said pipes
and/or;appliances-in_accordance with,the provisionxs of-the`Pliulibing-Code of the
-hof Cupertino; and-all other-lawsapplicable thereto J...._ ..-
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CONTEACro0. AGENT 4
Phone ��� to 9. Approve
{ J � PLUMBING INSPaCTO
Remarks (Check ✓)
Type of Appliance I Units Fees II New Replace Relocate
GasRanges ( 11
\Usll Heaters
Gas Plates
Circulating Heaters �11
Blower Furnaces
Gas Fired Boilers ( ��
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit II
Floor Furnace
Miscellaneous
NAME TYPE) I I II
I� I
S -ti S
pp [ante Fees
Inspected and Approved ..............:... ............................... ................
, _.
DATP INSPP.CT00.
HOUSE GAS PIPING
Number of Outlets ':K I Size of Main
Gas Piping Fees
Te_J-.�
sted and Approved ... .._- . ... �... .. ....... .................:..........
DATa INSPECTOR
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