2200 (2) dd
LOT NO.
.�' APPL CATION'FOR GAS PERMIT
z i CUPERTINO
lMAR 5 18rLDE
Y LL
abo
3 u Date — I ft Permit No.
�\1J Fee'S 4L
4 u Application is hereby made to the City of Cupertino for a permit to install gas pipes
o i and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
zz N and/or appliances in accordance with the provisions of the Plumbing Code of the City
i m of Cupertino, and all other laws applicable thereto.
tx
J Use of Premisesn /
00
/ 1
o` Owner Address la ec o �
zJ
o By Address
I—w Phone
W z
ww
i o State License le'9'—E 71 Approve
-U R
Remarks (Check ✓1
Type of Appliance Units Fees New Re lace Relocate
Gas Ranges
Wall Heaters _
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnace
4uspended Unit
Floor Furnace
Miscellaneous
(NAME TYPE)
HOUSE GAS P PING
Number of Outlets ze of 1 Iain
Gas Piping Fees IE
Tested and Approved ............. . .. .... . .. ........................................
DA a INSPaCTOR
1i
Multi-Nouse Gas Inspection Card
Gas Permit No. ....................................
GAS PIPING APPLIANCE FURNACE
APT. USTED AND INSPECTED AND INSPECTED AND
NO. PPROVE,q APPROVED APPROVED
1. !q /.�
2.
4.
3.
6.
7.
8.
9.
10. P
11. '
12.
13.
14.
13.
M.
17.
18.
19.
20.
21.
22.
`23.
24.
11B 1/89.500