2491 aa3 0/W,
630 HCl (.�) Ate/ LOT NO.
NO. HET
P�
?( JAUG
� L ,TION FOR GAS PERMIT
b 3 1963
CITY OF CUPERTINO
vp Date O — 9 — �'� , 195_ Permit No.
�N CITY OF CUPERT�""% Fees
Application is hereby made to the City of Cupertino fora permit to install gas pipes
I _ 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
of Cupertino, and all other laws applicable thereto. -
u
Use of Premises
:a
in
Owner \�" / ` _ Address S.4AJ ' WA AJCIS CO
ByWi�� — c7atJ r S Address
ONTRrER AGENT
Phone (� B Approved
61�PLUMBING INSPECTOR
l:
Remarks (Check ✓)
Type of Appliance I Units Fees I New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates 1 II I
Circulating Heaters I II I I
Blower Furnaces I I
Gas Fired Boilers
Warming Ovens
Percolators I I I
Griddles II I
Steam Tables
Gravity Furnaces
Suspended Unit
_Floor Furnace I I
'Miscell'aneous
NAME TYPE)
X41 � I ( I II I I
I I II I I
I I II I I
I I II I I
Appliance Fees ----
Inspected and Approved ._...........:...L........---..........-- ---............._...
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets 1 4,
L I, Size of Main (l—
Gas Piping Fees I I r
Tested and Approved ........................I...............................................
TATE INSPECTOR