2434 /VO 5S- LOT NO.
NO. STREET
APPLICATION FOR GAS PERMIT
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CITY
OF CUPERTINO
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JUL (. 17
Da ! * 0J r�� 196_ Permit No. 3
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Pee
n w Application is hereby made to the City of Cupertino for a permit to install gas pipes
O aad%oilgas appliances)ls'ilitedtori the reverse side hereof, and agrees to install said pipes
i in and'/or appliances m accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all rpther laws a licable thereto
Use of Premise
00
oane - ✓G?'� Address
z By v p QLD A� / Y Address
0 CONTRACTOR, AGENT
3 rT.e O — 74 /�
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oState License / /O Approv
U (2 3 / . PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
as Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
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HOUSE GAS PIPING
Number of Outlets 1 / Size of Main
Gas Piping Fees .S'O
Tested and Approved . _ ........-3i.... .. . ....._.__........._.....
DATE INSPECTOR