51145 Q /G O/ •Ill LOT NO. Ar—
NO. ^TREET
APPLICATION FOR GAS PERMIT
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° a Ua ®, N196— Permit No. X 11
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� 0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
o . a1-0psy as//,,�� plizk;c���aa£�e����t�tthe reverse side hereof, and agrees to install said pipes
r : an�c%or app�li nce �adsd�d teUith the provisions of the Plumbing Code of the City
<w of Cupertino, and all other laws applicable thereto.
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LL Use of Premises
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50
1- 3 Owner Address
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° CONTRACT is R, AGENT
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a o State License 3 0 ��
Ll0 7 Approved ��. / �,6.d`` /
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_ / PLUMBING INSPECTOR L/
Remarks (Check ✓)
Type of Appliance Units Fees 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 Size of Main
Gas Piping Fees
Tested and Approved ......
DATE INSPECTOR