2803 �2✓ LOT NO.
FAR
APPLIC LWIIO� N FOR GAS PERMIT
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< 271964 tj'ir1 OF CUPERTINO
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3 < Da}� I t�t�196� Permit No.
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0 Application is hereby made to the 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
and/or appliances in accordance with the provisions of the Plumbing Code of the City
<w of Cupertino, and all other laws applicable thereto.
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Use of Premises
00
Address 'Q69
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O CONTRACTOR,AGENT
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0 State License ( Approved
0
^n PLUMBING INSPECTOR
Y
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Nall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Giiddles
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 .... ...-4 .1... _ _ .._.._......................
DATE fNSPECT01