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fn4 CATION FOR GAS PERMIT
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3 U Date 19 — Permit No. -5`"0-2 7,
i (�I ' Fee S
CITY %iicAbighgLRTl1N0de to the City of Cupertino for a permit to install gas pipes
'o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
a �`- and/or appliances in accordance with the provisions of the Plumbing Code of the City
wof Cupertino, and all of er laws applicable thereto.
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,. Use Of P emises
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3 Owner' �'I e/eC G a Address
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�,; CONTRACTOR, AGENT
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a0 State License// y'Z Approved_ /
']I�If PLUMBING INSPECTOR V
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
Miscellaneaus
NAME. TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved ..........._...__....,..._.......... ........
DATE. INSPECTOR