51028 LOT NO.
NO. STREET
IAPR 6 AMI ,ION FOR GAS PERMIT
_ - CITY OF CUPERTINO
Wi
C OF PE&�INO -16 y
3 V D. e J 196 Permit No. s
W a Fee•$
o Application is hereby made to the City of Cupertino fora permit to install gas pipes
o W and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i N and/or appliances in accordance with the provisions of the Plumbing Code of the City
< W of Cupertino, and all other laws applicable thereto.
Wx
• ter
Use of Premises
00
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O 3 Owne
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o By T_-l1Ca% Address S�3
CONTRACTOR, ENT
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- 0 Phon Wz /
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o State License%�j-3 �� Approved
_U PLUMBINGINSPECTOR'
Remarks (Check ✓)
Type ofAppliance 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 -E
Floor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING _
Number of Outlets Size of Main
Gas Piping Fees
Testedand Approved _...................... ...'._...... .................................
DATE INSPECTOR '