2650 ('NO a+ \TI EfETT S I P
N I APPLICATION FOR GAS PERMIT
wZ DEC 16 1963 ice? OF cuPExTINo
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Application is hereby made to the City 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.
a Use of Premises /o >� l &( e
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r3 Owner Address
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, By Address
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3 F XONTRACTOR, AGENT
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°< o State License i Approve
IIn PLUMBING INSPECTOR
Remarks (Cluck ✓)
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
F!oor Furnace
SH
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved . ....— .T�.. . .. .. .... . . . .................
/ ATE INSPECTOR