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APPLICATION FOR GAS PERMIT
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3 ¢ Date ��Ta �G T�R196 Permit No.
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0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
o 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 othe laws appl.cable thereto.
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Use of Premises
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3 Owne , Address
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< o State License IT Approved
U PLUMBIA'�G INSPECYOA
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
Steam Tables
Gravity Furnaces
Suspended Unit'
'Floor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets I t I Pize.0 Main 1
Gas Piping Fees i
Tested and Approved '`��
Pproved . ._1......._._.............................---
DATE 1 INSPECTOR