100026 /OYl / LOT NO.
NO. IAEET (21
aION FOR GAS PERMIT
z i T OF CUPERTINO
FfAPR 191965 a ooz
3 < Uate 196— Permit No.
u
0
�+IT (�� (� p 1nI Fee S —
° l� 41 lic4 " 'w e mtothe 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
i w of Cupertino, and all other laws applicable thereto.
us
00 Use of Premises
3 3 Owner Address
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2 z By 6
Address c SA& 7
° CONTRACTOR, AGENT
3a` /
— m Phon
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ww671
o L4��
U ,State License Approve
(\�_- PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees I� New Replace Relocate
Gas Ranges
Will 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