51116 (2) NO. STREET
PLICATION FOR GAS PERMIT
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-`ze p{j nTY OF CUPERTINO
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3 < Date' 196— Permit No.
w LL �•,L Fee$ / 3a
° Cl I J'1) ti t e to the City of Cupertino for a permit to install gas pipes
o : and/or gaS apN?t� e, n the reverse side hereof, and agrees to install said pipes
> : and/or appliances in actor ante wit the provisions of the Plu bin Code n the City
<w of Cupertino, and al&0e laws a ica le thereto.
j W Use of Premise eL
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3 Owners Address �0 rci
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� z By �� sN Address--
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° CONTRACTOR, AGENT
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— Phone
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a,S L INC INSPECTOR I
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 ..........._.._.....-r-------_ ......................_..._...
DATE INSPECTOR