51037 (2) 11137 Linda Vista Drive. 168
LOT NO.
NO. STREET
APPLICATION FOR GAS PERMIT
04 CITY OF CUPERTINO
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IX � /03
O U Date ®CT 7 1,%4 196— Permit No.
O Application is hereby made'to the City of Cupertino for a permit to install gas pipes
o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
iN and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino; and all other laws applicable thereto.
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0 a Use of Premises
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> � Ward Crump PO Box 634 Cupertino
3 Owner Address
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B CROWLEY CO Address 855 Jackson Mt View
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30YO 7-5578
GE)NTRA6TE)R, AGENT
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o State License I Approved
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Remarks (Check ✓)
Type of Appliance Units Fees II 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 1
NAME TYPE)
HOUSE GAS PIPING
- Number of Outlets t / I Size of Main
Gas Piping Fees .�h1
Tested and Approved .......... ...__......I.............. .................................
DATE INSPECTOR