2698 LOT NO.
KEB
CATION FOR GAS PERMIT
CITY OF CUPERTINO
W 2 8 1964 c_
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° a Date —�-- - �"-�`� � 196 -Z Permit No. /V_ (Jx
3� wIC Ut Uurt ; .� Fee
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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
a w of Cupertino, and all other laws applicable thereto.
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w Use of Premises
00
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o a Owner ���e� Address
J z By _� .�`�^"z—z'-^i' Address
° CONTRACTOR, AGENT
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— Phone
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of State License Approved
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Remarks (Check J)
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
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
J�
HOUSE GAS PIPING
Number of Outlets a Size of Main
Gas Piping Fees
Tested and Approved J.. .. ...- �....
DATE IX's PECT00.