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2138 (2) dl/ y a 7 I /T—�e..0 ��. LOT NO. 1 NO. STREET ' A� 1tr APPLICATION FOR GAS PERMIT CITY OF CUPERTINO g ry � ) Dat 7, JAN pJAN ` �— y 19K3 Permit No. 0]C'13(! CITY G� C PERTINO o - ( � -.Fee.$_./�5`• Application is hereby made to the City of Cupertino fo'r a perm t to install gas pipes ` and/or gas appliances as listed on the reverse side hereofand 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. .� a Use of Premises—_ . ;. � � o+z k '1. �y yh�. 4 ... ♦...r [K i5 0 OWneL ' _ — - ✓ _ Address Address" Lip CONAGENT Phone=�? TRACTOR, Approved l 'W✓` PLOMBING INSPECTO Q - r ` � Remarks (Check ✓) Type of Appliance I Units Fees II New I.Replace_I Relocate Gas Ranges r- Irk Wall Heaters I I �::."�.I . ;•,. ,`,7-- Gas Plates I I II I 14 Circulating Heaters I I II I I Blower Furnaces I I II I I Gas Fired Boilers I Warming Ovens I II Percolators i Griddles I I ii Steam Tables 1 Gravity Furnaces Suspended Unit i II Floor Furnace liscellaneous I I II -_ I NAME TYPE I I I� I i � I ,I -•, pp lance Fees Inspected and Approved ..............:.:.I................... ......>..... ..; ...... DATE INSPECTOR +dant HOUSE GAS PIPING aL Number of Outlets I I Size of Main I J _ Gas Piping Fees —�— — Tested and Approved ........... .. <................ DATE INSPECTOR ""1x^ ( � � / : / . . . ©` ) nom \ : 02 § kz \ \ k ! § 0 . . tm} )}