100063 tL LOT ti0.
NO. Q VF.T
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AP,LP!!!-'ATION FOR GAS PERMIT
< 3TY OF CUPERTINO
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0 3''1966
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3 u Dare a 5 0 te
�0 �,196_ Permit No. d U 3
W LL CITY OF CUPERTINO Fee S
o Application is hereby made to the City of Cupertino for a permit to install gas pipes
'oa and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
and/or appliances in accordance with the provisions of the Plumbing Code of the City
in
of Cupertino, and all other laws applicable thereto.
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a o State License Approved
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Remarks (Check ✓) -
Type of Appliance Units Fees I New I Replace I 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
Testedand Approved ._.................................... ................
DATE INSPECTOR