2485 LOT NO. Q, S
® T KATION FOR GAS PERMIT
AUG 13 19631 CITY OF CUPERTINO
Ite v —•*�� 195_ Permit No.
sli; _
r• Fee E
Application is hereby made to the City of Cupertino fora 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.
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Use of Premises r—h
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Owner
` /,I.� Address`'t\a (=2A I') C.1 S c a
ByWIL�� —��75 Address
p _ CONTRACTOR, AGENT
-J{WJ Phone C �— I L Approved
PLUMBING INSPECTOR
Remarks (Check d)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters I
Gas Plates I I II I
Circulating Heaters I II I I
Blower Furnaces I II I
Gas Fired Boilers
Warming Ovens i
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace I I I _
• I I II I _
Miscellaneous I I itNEW
NAME TYPE I I
I IGl1 � II
I I II I I
I I II I I
I I II I I
Appliance
,Inspected and Approved ..............:...I.
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved ........................I............................................
DATE INSPECTOR
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