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14PPLICA�ION FOR GAS PERMIT
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�� 1�_ Permit No.
3LL / Fees
° Application is hereby made to the City of Cupertino for a permit to install gas pipes
'o i and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
r and/or appliances in accordance with the provisions of the Plumbing Code of the City
<w of Cupertino. and all other laws applicable thereto.
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Remarks (Check ✓)
Type of Appliance Units Fees II 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 j
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets -t� ize o Main
Gas Piping Fees - , /
Tested and Approved ........ �-�/a. _ ..... .... ...... ..........................
UAT INSPECTOR