2807 0a vW a-CXfC- DO"'ar xo.
NO. STREET
RPLUT ON FOR GAS PERMIT
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® I1 ';OF CUPERTINO
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° aDate , _196Permit No. O
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° AFgTVon0`tierbb�iai R fherCity 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.
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Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
'Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters S
Blower Furnaces
Gas Fired Boilers H
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
.o
Floor Furnace
Miscellaneous \
(NAME TYPE)
4
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Pipipg Fees
Tested and Approved ..................................
DATE INSPECTOR