2488 033r l CYC •A� LOT NO. (T:�
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LICATION FOR GAS PERMIT
1 AUG 13 1963nJ CITY OF CUPERTINO
V
�1 I��t4 ?r 0-1, 195_ Permit No. I, / t/
11�A 1 V- - - - - - - - — -- - - Fee $
Application is hereby made to the City of Cupertino for a permit to install gas pipes
r and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
1t and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto.
y
Use of Premises •_1
in Owner < t � AddreslsAA„� ` �•ISC
1 >�
By�11 LL1 — ��l►J t C Address I Str0 1d9. Q�
CONTRACTOR, AGENT Approve
-�
./lyJ7 Phone �— I Lf-0D ;• j PP
If PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance I Units Fees I New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators ,.
Griddles
$team Tables
Gravity Furnaces
Suspended Unit II
Floor Furnace
Miscellaneous
NAME TYPE I '
S
Appliance
Inspected and Approved ........... ...............................................
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees —
Tested and Approved ........................I....................._........................
/] TATE
INSPECTOR