51009 03oTc�
LOT NO.
NO. a E
i ION FOR GAS PERMIT
z ® OF CUPERTINO
xW fSEP2 1965
K _ r
3 Date 196 S Permit No. a 0
CITY. OF. Fees �r�
� O Application is hereby made to the City of Cupertino fora permit to install gas pipes
'o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
Z a and/or appliances in accordance with the provisions of the Plumbing Code of the City
i m of Cupertino, and all other laws applicable thereto.
] „ Use of Premises 4/7 f
00 �
> N
O <
i Owner1k ly/ xs` s. l Address //i fin Wa/1 _l
E /
zAddress
o By X�«1� .��i;+y 4%�iMlJ.riG
3 < CONT&ACPOR,AGENT
— � Phone `767—/39S
ao State License X /� �2 Approved
-U PLUMBING INSPECTOR
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 Z
Testedand Approved .._.._............._. ._:............_.............................
DATE INSPECTOR