NO PERMIT NUMBER li I LOT NO. Zoo
NO. STREET
TION FOR GAS PERMIT
W = OF CUPERTINO
e /APR 22 1966
3 U Dare 196— Permit No.
W 'J Fee E '
° C11YpliQrton ICU the City of Cupertino for a permit to install gas pipes
°o : and/or gas appliances as RMthe reverse side hereof, and agrees to install said pipes
i N and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all el7FFlaws licable thereto.
W
u i
w r
Use o Premises
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i 3 Owner .Address
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z By Adds@
° CONTRACTO AGENT `9Q
3 0 Phone � 4L G�'� �(
0 o State License '� / L110 Approved�wi �/.�
g C% PLUMBING INSPECTOR /
V
Remarks (Check ✓)
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 Main
Gas Piping Fees 17
Tested and Approved ._.._......._.._._ ._:._--------...............................
DATE INSPECTOR