2486 d- U 3 • / _ 1 LOT NO. 4-
®
411�jICATION FOR GAS PERMIT
AUG 13 1963CITY OF CUPERTINO
IT[ %*Win . T'7 195_ Permit No.
11 1 vl v�+l Fee $
Application is hereby made to the City of Cupertino for a permit to install gas pipes
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.
:a
'2 Use of Premises—
Owner
remises Owner �r �� Address S/A6 I-CAJC( sCO
By CIO{1..1 tk" o IJ Address 50o S 10�C♦ (� I
CONTRACTOR, AGENT
Phone d 40 0 Approved /
PLUMBING INSPECTOR
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 j
NAME TYP/E
Appliance Fees �—
Inspected and Approved .._. ..............
DATE, INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of M
Gas Piping Fees
Tested and Approved ........................I...............................................
GATE INSPECTOR