2775 fl LOT NO.
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LIC(TION FOR GAS PERMIT
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zi ITY OF CUPERTINO
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3 < 14,ijj� FIIPERT'N0196� Permit No. _02 5
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0 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
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.
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Use of Premises e--
20
3 Owner / UGc iOi Address/5%rJ�iU.
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O CONTRACCOR,A T
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— 0 Phone X96—.396
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oState License a 9 y I Approve
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Q PLUMBING INSPECTOR \
Remarks (Check J)
Type of Appliance Units Fees II New Replace Relocate
Cas 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
Tested and Approved:.. \.�. . .................
DTE [NSPECTOA
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