51087 (5) 2Z ZO� / /C C �{ I�RH LOT NO.
NO. STREET
N /rn��1P�CFC TION FOR GAS PERMIT
G- � OF CUPERTINO
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3 u Uate / 196 Permit No��� �+
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� f the Gt of Cu ertino fora ermit to install as n es
o W and/or gas appliances as este on he reverse side hereof, and agrees to install said pipes
> r and/or appliances in accordance with the provisions of the Plumbing Code of the City
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of Cupertino, and all other laws applicable thereto.
4 Use of Premises
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3 Owner -.,V lee rw ni /0r Address ZZZ�� ��Cl fta'1J
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AGENT
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Phone2.. 93 - 35Y3
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oo $tate Licens�9o��� Cs3 Approved /
-U/J"L PLUM 'G I' SPECTOR I//
Remarks (Check ✓)
Type of Appliance Units Fees 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
;TAME TYP )
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Testedand Approved;...,_..............._.,....._.____....----.._._..___......
DATE INSPECTOR