2748 LOT NO.
APPLIC1 N FOR GAS PERMIT
W MAR 111964 IOF CUPERTINO
Y
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3u Da :nV? C1IPER.TrIRlrjl96Y Permit No. S�
iFee $ �—
O Application is hereby made to the City of Cupertino for a permit to install gas pipes
o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
iand/or appliances in accordance with the provisions of the Plumbing Code of the City
aw of Cupertino, and all other laws applicable thereto.
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n Use of Premises /<
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3 Owner ecP �0AWIrS Address
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By9 7; Address JoXo jCO � � s )
AGENT
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oState License /t"'7 —l..9 • Approved `
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PLUMBING INSPECTOR
Remarks (Check J)
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
Gr,vity Furnaces
Suspended'Unit �-
Floor Furnace
Miscellaneous
NAME TYPG)
HOUSE GAS PIPING
Number of Outlets 1. Size of Main
Gas Piping Fees I/
Tested and Approved ...... ............._....
AT \ INSPECTOa