510277 ® p T ' ET
AP W ION FOR GAS PERMIT
w z ',o CT 1 X965 TY OF CUPERTINO
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I "rr 6 196 Permit No.
W LL lr� 1 I lJf 1jurEn I mu Fee $ 3
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Application is hereby made to the City of Cupertino for a permit to install gas pipes
'o Wand/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�aCpplicAble thereto.
00 Use of Premises /.a/i�l
3 Owner 1 A Q/ C /(1/ Address�0 O TQc �ni�o/Q
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z By �` J _ Address 761, 2Xe Cl—K r;-o
CONTRACTOR, AGENT
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atate License--?(:5p7ys Approveo LUMR
ING
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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 �� Size of Main'
Gas Piping Fees
Tested and Approved ..........._.._...........:...........................................
DATE INSPECTOR