2763 .(� N �L �,,�5 LOT NO. ' /U
APPLIC N FOR GAS PERMIT
w z MAR 2 7 1964cI�OF CUPERTINO
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O < Date _ - 'p196-Permit No.
U En . 1 i
Fee $ // i)
O Application is hereby made to the City 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
> H 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 Prem
ises _ Q •� �-0��/{/-!/
00
a il"a 1 %/ 10
o a Owners O/y/�'/7 �o Address �� ' �</yJ�j
Address wl�/�,QY
y CON•TRAC70R, AGENT / /
- < Phone
w zmo
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d /,7 6A— 9 Approved
I State License
U / / PLUMBING INSPECTOR
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'
(NAMP TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main 3
Gas Piping Fees
Tested and Approved ......'..p.!rI ....................
DATE INSPECTOR