100030 0(0Ir 1 Q)04 LOT NO.
NO. s'I'�EE}�
'�KP41iT
N FOR GAS PERMIT
` VAPR
OF CUPFRTINO
o 2 9 1965
QLLo
O a Uate I96— Permit No. /O (% U
3 LL CITY OF CUPERTINO Fee $ /
O Application is hereby made to the City of Cupertino for a permit to install gas pipes
'o and/or gas appliances as listed on the reverse side hereof, agrees to install said pipes
s and/or appliances in dance with the provisions of e arobiLdf the Ci
V)
of Cuperuno, and a nth I livable thereto.
u t
� w Use of Premises MD
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00 /
3 Ownerx �, it&42v0 �— Address Ok-,&0.Qr-, -+
oa
zJ
zBy I�u.-i 1.'$Q Q Address
CONTRACTOR, AGENT
m
Phonet
W
w w
0 o State License C�wh Q 2.e Approve
U PLUM NG INSPE R
Type of Appliance. Units Fees Remarks (Check ✓)
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
Testedand Approved ..................._._ ......_......_._......_.. .................
DATE INSPECTOR