2612 ////' / s i—v �� �7 .Ll C- LOT NO.
NO. 5'%T1 E T Il
�PPL-ICATIOf�N� FOR GAS PERMIT
z < d OF CUPERTINO
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O NOV 1 1963
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0 ' Date OG7 2-9 196.? Permit No.
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� 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
> r and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all other laws applicable thereto.
RESIDENCE
LL Use of Premises
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r 3 Owner Address
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G,�ot./G6�/ Coy Address �11T57
O By CONTRACTOR, AGENT '
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— m Phone 7-53 7k
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State License �6G�Q� Approved- Q'L0A rl
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PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
was Fired Boilers
Warming Ovens
Percolators
Griddles
J.Stearn Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
!NAME TYPE)
HOUSE GAS PIPING
Number of Outlets 1 y Size of M"in 3¢
Gas Piping Fees 145-01
Tested and Approved ..5..�-. ..(.I(•�/// �. 'e ----
DATD t INSPECTOR