2005A9 .�I? /�'.. I QG^$NCryY" 1 LOT NO
NO.VfJrLSTRE T
APPWCATGION FOR GAS PERMIT
AUG 31 ig 62 C OFFCUPERTINO
Dateu 9 �/E� p p 190 — Permit No. w'- () 0 S
CIT GF S �I LRTINC Fee $ 3�
Application is hereby made to the City of Cupertino fora 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.
Use of Premises cue GrNe,- 'S
� Owner
Byt/i�r
CONTRACTOR, AGENT
Phone - E-
14, i 1P IF
Address &Z'q . e < <✓e—
Addr0AT'F''e'
Approved N /�_
PLIIAIBING INSPECTOR
Type of Appliance Units Fees
Remarks (Check ✓)
New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit -
Floor Furnace
Miscellaneous
NAME TYPE) I I
I I V �-
pp lance Fees
Inspected and Approved ..............
..........................................
DATE.
HOUSE GAS PIPING
Number of Outlets 2i Size of Main
GasPiping Fees I /
Tested and Approved.....................................................................
DATE INSPECTOR