2717 LOT NO.
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0 4APPLICATION FOR GAS PERMIT
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CITY OF CUPERTINO
' 0 V111 2 1964 2
0 ¢llaze 3 — `2__ 196 Permit No. v /
3 CITY OF CUPERT",^ Fee$
0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
'o 1- and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
r 1- and/or appliances in accordance with the provisions of the Plumbing Code of the City
wof Cupertino, and all other laws applicable thereto.
LLUse of Premises
00 Lc� 41 CC r'
o < Owner 4 S Lt� Address
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� z By �`� ra c� Address I .S'LI Tr L,A
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< CONTRACTOR, AGENT
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"0 Y State License Cl �' Approved
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Q PLUMBING INSPECTOR
Remarks (Check J)
Type of Appliance Units Fees I 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 _
lFloor Furnace
Miscellaneous
(NAME. TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
s Piping Fees
ested and Approved . .........
DATE tN5PECTOR
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