51145 (2) LOT NO. `�y
NO. R
I ION FOR GAS PERMIT
z i ® OF CUPERTINO
r o (MAR 22 1966
0 ' Date 196_ Permit No. Z
3a CUP
u CI�Y OF10
W Fee 8
o pptication 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, and agrees to install said pipes
N and/or appliances in accordance with the provisions of the Plumbing Code of the City
< W of Cupertino, and all other laws applicable thereto.
Use of Premises _
00
3 Own Address
z_j<
V
z B 4b Address
O CONTRACTOR, GENT
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— n Phon c _ �S--cF �, 2;(' i";$p
Ile_� z
W w
o f State Licens 3 C • Z 3 e,Ya Approved-
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a
PLU"141 EC�' /
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 Size of Main
Gas Piping Fees
Tested and Approved _.......------......_ ....---------............_...................
DATE INSPECTOR