941IV -
LOT
NO. STREET
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APPLICATION FOR GAS PERMIT
OF CUPERTINO
DateV.�§&Ur li _ Permit No. 50
IMAR 221 Fee $
�o A licat'on er Q� I of Cupertino fora permit to install as pipes
and/ o p6sTa1 . X's � b` ge verse 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.
C:
Use of Premises
2
cis Owner AM I ` !U Address f�`3�/� D ,/
By,140— Address -,'J -/-S 4 � s 4 1161—
O R,&7 !'t�
Phoneme Approv
PLUMBING INSPECTOR /�
of Appliance I Units Fees 11 New
Wall Heaters
Gas' Plates
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators I -T -1 I
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
i
Appliance tees I 1 II 1 1
Inspected and Approved ---------•--......
11
• DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved - ��INSIECTOR
....
SATE