51139 wX W3
LOT No.
NO.
I ION FOR GAS PERMIT
i = ® OF CUPERTINO
W
Y R (JUN 22 1965
4
0 u Date 1 16— Permit No.
W C�l )�RTINO Fee a
° Xpli9ttoF n is ere y made to the City of Cupertino for'a permit to install gas pipes
' C1�o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
'z U) and/or appliances in accordance with th rovisions of the Plumbin Code o the City
i W of Cupertino, and all other,laws a lic 1 hereto.
x c
JLL Use of Premises
O O
> N
3 Owner 9 Address
ZJ
�.p By yti A4'' Address At J�
F
ON 6XCTOR, AGENT
— m
Ph4 16Z—
nz
WW
o2 State License Z�7 Approve
1
-0 �� PLU. ING INSPECTOR
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