51027.7 8 3 / 6� \2A.tQ� LOT NO.
NO. STREET
�AI TION FOR GAS PERMIT
w z ® OF CUPERTINO
1
AUG ,�/O @27 z
- 9 1966
3 a Uare 196— Permit No.
U
FerE /XV
' 0 Cl�yplio onG� ® the City of Cupertino for a permit to install gas pipes
'o and/or gas appliances as ate 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
i w of Cupertino, and all other laws applicable thereto.
Use of Premises 19A
2a
J N
ZJ OwnerQ� A;/V219 i✓ Address C:5 cS—�
z By T// / 6 u Address ,! G )xr—
O CONTRACTOR, AGENT
Phone
u Z
ao State License ,I ��in ApprovedvC
_ 0 I PLUMBING INSPECTO
Remarks (Check ✓)
Type of Appliance Units Fees IIS 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 / I Size of Main t�
Gas Piping Fees Ii 5 0
Tested and Approved .........._..,-.....-- ._:_.____......_.__.....---_... ...
.
DATE INSPECTOR