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N FOR GAS PERMIT
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° < Date 196_ Permit No. J
PE YYcatOs {UyppnnOheinstall
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City of Cupertino fora permit�insta(gas pipes
o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
r and/or appliances in accordance with the provisions of the Plumbing Code of the City
<W of Cupertino, and all they laws applicable thereto.
S W Use of Premise 00
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CONTRACTOR, AGEN/�
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o f State License/72Approved
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�� (�// PLUMBING INSPE TOH 1 /
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
ees' -Tested and Approved ...._.................. ...................._..._.........__----
DATE INSPECTOR