51009 STREET
N° APPLICATION FOR
w CITY OF CUPER
Y °
SEP i XM5 lel W9W9
6:sW
3 U Date f 3 196.r Permit No. / �t?�
Z LL CITY OFer6I II�In
° Application is hereby made to the City of Cupeftmo for a permit to install gas pipes
o r 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
<W of Cupertino, and all other laws applicable thereto.
u x
LLUse of Premises
00 dd T
3 Owner �T�' 4i /Q WI-I Address A4'µ11 G,1440q0*W1
J z By Mfi1V*4 1111yA p2W . Address
° CONTRACTOR, AGENT
s0 ZT1 - 13th
— Phony
aState License S� 9 y L Approved
—U LUMBING INSPECTOR
Type of Appliance UnitsRemarks (Check ✓)
. 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. V
Tested and Approved ........ ......................._........
DATE INSPECTOR