1982 GASNO.
D �P�
!AUG 221962
CITY OF CUPERTIIVO
)N FOR GAS PERMIT
OF CUPERTINO
195_ Permit No.
5v
Fee $
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 applicabl reto.
,,-,.,
Use of Premises
Owner _ Address
By IL Address
CONTRACTOR, AGENT'
Phone !� L — 8 \ S9 Approved
PLUMBING INSPECTOR
of Appliance I Units Fees 11 New
Gas Ranges
"Vali Heaters
Gas Plates
Heaters
flower Furnaces
Gas FiredBoilers 1
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
NAME TYPE) ,
Appliance Fees
Inspected and Approved -- ------
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main
vas Piping Fees
Tested and Approved P:TOR
�.�.
_ J
I, the undersigned do hereby certify/ that
I am the owner and occupant o; he si
family dwelling at lal,30-
o ich am making applicTtion to do
L work as a homeowner.
also ceirtif I w' 11 not hire any
non -licensed or contractor,
but will do this work myself.
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TELEPHONE NUMBER