2723 J �D • LOT NO.
N � TPPj
T FOR GAS PERMIT
za I P CUPLRTINO
w Z MAR 4' 1964
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° JDate " T __CU ,pl � Permit No.
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LUrtK Pee
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� Application is hereby made to the City of Cupertino for a permit to install gas pipes
o a 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
Z of Cupertino, and all other laws applicable thereto.
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j Use of Premises o"' /
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3 Owne ^_-��r it e2 ' Address
_ t� . e . ����
� z 13y Address
CONTRACTOR,AGENT
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- m Phone �' e7Z6 ' -:2
0 o State License �y S 9 Approved
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PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Stearn Tables
Gravity.Furnaces
Suspended Unit _
Floor Furnace
Miscellaneous
(NAMF TYPE)
i O
HOUSE GAS PIPING
Number of Outlets 2 Size of Main
Gas Piping Fees
Tested and Approved ..'. _....... ..... ... ... .............
DATE INSPECTO. .R.................