51140 �OS33 v LOT NO.
NO. STREET
��APPLICA FOR GAS PERMIT
z ` G � CITY OF CUPERTINO
3 a Date (Nov – 3 1966 1196— Permit No.
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r,ApRlicatiQn i;-h�e{�¢y��de�totthe City of Cupertino for a permit to install gas pipes
`o and/hi gas �pphanctdKs�4dl�on(the reverse side hereof, and agrees to install said pipes
i - and/or appliances in accordance with the provisions of the Plumbing Code of the City
w of Cupertino, and all other laws applicable there
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Use of Premises
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3 Owner Address
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CONTRACTOR, AGENT
30– Phone
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etate License �`� oG� Approved
a PLUN113ING INSPECTOR
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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 Size of Main
Gas Piping Fees -.3
Testedand Approved .....-----.__...._ ...:-------..........-----_...............
DATE INSPECTOR