2760 ' LOT NO. ''•
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APPLICA FOR GAS PERMIT
I IAR 271964c : bFCUPERTINO
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3 U Date WI � i(7►ri �rN�F''�T_ I�196�f+ Permit No.
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O Application is hereby made to the City of Cupertino for a permit to install gas pipes
o 1 and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i m 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 �I��
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_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
G5avity Furnaces
Suspended Umt _
Floor Furnace
Miscellaneous
. (NAME. TYPE)
HOUSE GAS PIPING
Number of Outlets Size Of Main
Gas Piping FeesAIA
wwTested and Approved ...... i .. .�.. .... .........._...........f INSPECTOR