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PLU—f
ICATION FOR GAS PERMIT
APR26 966 CITY OF CUPERTINO
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l lau C 196 6 Permit No. S1//
W LL U i—N Fee E
Application is hereby made to the City of Cupertino for a permit to install gas pipes
'o i and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
=m and/or appliances in accordance with the provisions of the Plumbing Code of the City
i of Cupertino, and all other laws applicable thereto.
W
Use of Premises
00
.>. 3 Owner C_ - Jc -aJ Address
z By Z'1 C Address / 9 "L/i,
CONTRACTOR, AGENT
3a ?7 9
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Phone
o Vate License a`j`2 O o proved,?(-)
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_ PLUMBING INSPECTOR T�
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 3 Size of Main
Gas Piping Fees /
Tested and Approved ...........___..._.. ...:...._..............._....................
DATE INSPECTOR