2420 �VS/ .57! ,,�S •l_?'�C. V/1ti //Y LOT NO. / -
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APPLICATION FOR GAS PERMIT
w SWI 1`2 1y63 CITY OF CUPERTINO
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v6,2 Permit No.DatevVRvDCDT" ' T
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Fee $
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Application is hereby made.to the City of Cupertino for a permit to install gas pipes
`o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
> and/or appliances in accordance with the provisions of the Plumbing Code of the City
<w of Cupertino, and all other laws applicable thereto.
Use of Premises
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3 Owner G ffGc Address
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° CONT/R�ACTOR, AGENT
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U PLUMBING INSPECTOR
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Remarks (Check ✓)
' 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
Floor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets I Sze of eain
Gas Piping Fees
Tested and Approved ._..... ....�.. ._.._�.. . ......................................
DAT INSPECTOR
Multi-House Gas Inspection Card
Gas Permit No. . ----------------
GAS PIPING. APPLIANCE FURNACE
APT. TESTED AND INSPECTED AND INSPECTED AND
NO. APPROVED APPROVED APPROVED
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