510277 4'0 � sof/ LOT NO.
NO.N
f? 'g�;P7L'k%'qN FOR GAS PERMIT
OF CUPERTINO
AN 7 1965
3 a 196. �—
7
z n Permit No.✓/O '
Date
=LLCITY OF WERTINO
w
0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
o < and/ gas appliances as listed on the reverse side hereof, and agrees to install said pipes
r 1- and/or appliances in accordance with the provisions of the Plumbing Code of the City
wof Cupertino, and all other laws a licable thereto.
u i O
r f
Use of Premises
00
> N O Owner Address l c_ -
0 3
Z J A �•J/�
z By //�` VS �1� .�'r+.G. Address ^ C'
O CON ACTOR, AGENT
3 m Phone
o f State License O G'/c 7 7 Approved
G U I� 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
Floor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved .....................
...i--------DATE INSPECTOR INSPECTOR