2613 iiiy
.S.4.0%9 �EieE-.ry ':Z?�" LOT NO. /ZI
No.
A•PPN�^7SPPLI r`
GAITION FOR GAS PERMIT
w F(N'OV
OI'DY OF.CUPERTINO
1 1963
o U Date 'flG� 29 1963 Permit No. --2- `� /J
w CITY OF CUPER ' ` Fee Z
= LL
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.
Use of Premises RESIDENCE
00 /�'
3 Owner G!4wz, Address
0 a
z ByG,2aw�s� GO r Address /V,;r4/ J/iErd
CO ACTOR, AGENT
3 �
i
Phone
W
o0 State License �66�.� Approved QMCid't-C
mss
PLUMBING INSPECTOR
Remarks (Check ✓)
'Type of Appliance Units Fees I New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Ciiculating 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 y I Size of Main
Gas Piping,Fees 1/16.0
Tested and Approved ... ... .0:-_ . .......
/ ..............._.:...
DATE / INSPECTOR