2587 O`L�O�� I/-" /�-C�/✓L^' LOT NO.
O. �2\SYE'Et,11
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N � WPPLIC*TION FOR GAS PERMIT
W VOCT 3 1963 m 11 OF CUPERTINO
Y ° a
o a Date —�C — 196-3 Permit No.
3
UgCITY OF r
i Fee $
o Application is hereby made to the City of Cupertino for a permit to install gas'
piipes
o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i m and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all other laws applicable thereto.
Use of Premises /V4 y
O o
3 Owner. - L-�7- �/ Address
Z By � Address r
3 CONTRACTOR, AGENT +�
— m Phone ���
vz ry —
oState License �n /, � I Approved M1
0 PLUMBING 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
Grlvity Furnaces
Suspended Unit _
Floor Furnace
,Miscellaneous -
(NAME TYPE)
ro ' �
HOUSE GAS PIPING
Number of Outlets I Size of Nyin
Gas Piping Fees
Tested and Approved ................
DATE INSPECTOR