51145 (2) LOT NO. �✓x�
NO. STREET
AI TION FOR GAS PERMIT
<
FAR
OF CUPERTINO
2 2 1966
3 < Uate196_ Permit No. S ���5
= LL T � FeeE,���
° C� 1A(pl wn ' er l Baja the City of Cupertino for a permit to install gas pipes
'o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i a 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 S
! F
J LL Use of Premises
00
3 Owne Address
o <
z
z By o Address
3 �
CONTRACTOR, AGE
— � Phon WILLIAM �
a U State LicenseC S �r `Glc Y'oJ Approved G'ENEVICHI
PLUMBING INSPECTOR rl//
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 Unii _
Floor Furnace
Miscellaneous
NAME. TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved . _....................r-----.._..............................
DATE INSPECTOR