2164 (2) LOT NO. �✓�NO. q.
&IJAN
�T1 R GAS PERMIT
2 9190) tUPERTINO
Date I R'u , 19542 J Permit No.
CITY OF. CUPERTINO pre $
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.
v
Use of Premises—
Owner
remises Owner u S S Address
Liy pn1 Address tZ77A7TOR,
AGENTPhone `�@zz ApprovedMBING INSPECTOR(
Remarks (Check J)
Type of Appliance I Units FeesII New Replace Re
Blocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired oilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit II
Floor Furnace
Miscellaneous l I j I i
(NAME TYPE
Appliance Fees
Inspected and Approved ..............
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main 5 C1
Gas Piping Fees --
_�_._
Tested and Approved ...... ..9122L........ . . ................
TATE INSPECTOR