100022 (3) LOT NO.
STX
N No .APiPLICATIONJOR GAS PERMIT
`• ® CITY 16F CUPERTINO
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MAN1 1965 0 a Z
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Date 1966 Permit No. /,-)a,
3 LL 1TX OFu ��T�N�
Fee
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App ¢ahon Is here y a t o t e Qty 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
im 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.
Use of Premises
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3 Owner ,Address .Smiy�'1'Q
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O 3 CONTRACTOR,AGPNT�S2 3e- � 3
— < Phone
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State License Approve
—�' � f PLUMllING I sPCC R
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
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees / 5�
Tested and Approved ......._ ....... ............... ......._..-.........
DATE VISPECTOF