2786 LOT NO.
O. ® S E
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A PLI FION FOR GAS PERMIT
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R 17 1964 a OF CUPERTINO
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3 U Da�j �Uf �•- _�;�' Permit No. :P 7P61
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i''d I Fee $ JVD
o Application is hereby made to the196 City of Cupertino for a permit to install gas pipes
o` 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 alll�other laws//applicable thereto.
Use of PrEmises ,QC2ilZ!'!i
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O / CONTRACTOR, AGENT
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<U State License i Approved
p PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
WD-1 Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity*Furnaces
,iSuipended Unit
Floor Furnace
Miscellaneous
(NAME TYPE)
HOUSE GAS PIPING
Number of Outlets _2jjSi e of ain it
Gas Piping Fees /,, L z
Tested and Approved .__ . . .. .. ..._....... .............
ATE INSPECTOR