2630 111-2 1 LOT NO.
NO. 46S'f1 Q ,�
A . - C/-TION FOR GAS PERMIT
z1963 uiI ,Y OF' CUPERTINO
yW ,NOV 12
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° a Date 196_ Permit No.
3 LL CITY OF CUPERT ND Fee $
° Application is hereby made to the City of Cupertino for a permit to install gas pipes
o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
> and/or appliances in accordance with the pr �•isions of the Plumbing Code of the City
a w of Cupertino, and all other I s applicabl ereto.
,. Use of Premises —
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3 Owner
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° CONTRA TOR, AGENT
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ia State Licens Approved
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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
Gravity Furnaces
Suspended Unit 1.
Floor Furnace
Miscellaneous
' NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main _
Gas Piping Fees
. ..1.� ,�... ........... (.1..........
Tested and Approved
DA £ tNSPECTOR