2783r
LOT NO.
NO. Q<TRE
I, A ON FOR GAS PERMIT
Z
® CrOF CUPLRTINO
r l PR 1964 )X
p - 3
3 U Date / - 196 Permit No.
LL QF Q1JPERTi?,i� Fec $_ s�
O p i do s hereby made to the City of Cupertino for a permit to install gas pipes
o W and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i 1- 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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0 o Use ofrern
ises
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03 Ow i Address
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z By Addres
3 � � CONTRACTOR, AGENT
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nf State License -� Approved
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u PLUMBING INSPECTOR
Remarks (Check d)
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
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets I Size of lain
Gas Piping Fees
Tested and Approved ...........................
D TE 1 INSPECTOR
V