2010 A2 /1 NO./ � Lo'T NO. -
STREET
PCATION FOR GAS PERMIT
® OF CUPERTINO
Dat 195_ Permit No.
[ (f����� ppTT n(� Fee $ a
Cllp�licQbn i3hf�r RTJNOhe City of Cupertino for a permit to install gas pipes
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
of Cupertino, and all other laws applicable thereto.
v
Use of PremisesL�
Rt f/ /_/011 es7'V&Q�4
Owner _ Address S
By Address
Mle PLU/e , .§ONTACTOR, AGENT Appr e/ BING INSOR '
Remarks (Check ✓)
Type of Appliance Units Fees I New Replace Relocate
Gas Ranges
Nyall Heaters
Gas Plates = I II I
Circulating Heaterse'
Blower Furnaces. I I I
Gas Fired Boilers
Warming Ovens
Percolators I I
Griddles
Steam Tables I II I
Gravity Furnaces
Suspended Unit II _
Floor Furnace _
Miscellaneous
NAME TYPE)
.�✓ o,�' I I II I I
I I II I I
I I II I I
p�Fees �I
Inspected and Approved ..... ...............................................
DATP. INSPECTOR
HOUSE GAS PIPING
Number of Outlets I Size of ai I
Gas Piping Fees
Tested and Approved .. .�.�. r.`�_L.... ..
9 TE INSPECIYIA