51124 (2) 4/ LOT NO
!/ NO. STREET
N smft APPLICATION R GAS PERMIT
-z J -�-�zz jZ111TY OF CUPERTINO
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3 < Uate. `y 196 6 Permit No. ` v
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CITAppligtion@[q r�y rT�delCo the City of Cupertino for a permit to install gas pipes
o W and/or gas appliances as 7listted bn the reverse side hereof, and agrees to install said pipes
iN and/or appliances in accordance with the provisions of the Plumbing Code of the City
< W of Cupertino, and all other laws applicable thereto.
J 4 Use of Premises
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ao _State License s 33 Approve
y�_U P BING INSPECTOR f/
Remarks (Check ✓)
Type of Appliance Units Fees I� 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
Tested and Approved ....... ............................_....----
DATE INSPECTOR