51139 (2) V 1--16 SC:0 / �/ t_'41 LOT NO.
NO. STREET
PLICATION FOR GAS PERMIT
i 4 CITY OF CUPERTINO
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° a bate ��" 6--�- Permit No.
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� �pli�j ion reby made to the City of Cupertino For a permit to install gas pipes
o : and/or gas appliftjs�eon the reverse side hereof, and agrees to install said pipes
a and/or appliances in a r with the provisions of the Plumbing Code of the City
mof Cupertino, and all other laws applicable thereto.
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no State Licens - , -4Approved
r�C U PLUM INC INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees IIS 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 V -k—
Tested and Approved .................
DATE INSPECTOR