1360C•!
LOT NO.
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ITN FOR GAS PERMIT
�J Ju� OF CUPERTINO
J J {f 11
Date V , 195_ Permit No.
CITY OF CUPERTINO Fee $
Application is hereby made to the 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 of a s applicable-themto.
x Fes, -
`~ Use of PremiseiVii' YR; t ---I-"' F'IJ:LL •c•- • �a. -;;,lF: .=� -
.a
in Owner � Q�i 07Address - - ' •�= a .�
Addcess 0'.
qn CONTEACTORr AGENT
Y7 11 PhoneX 60— a — / q 0 �i I Approve
'I I \PLUMBING INSPECT
Type of Appliance I
Units Fees I
Remarks (Check?✓) .'
New I Replace,1111clocate
Gas Ranges
Wall,Heaters
Gas Plates ��
f
Circilating Heaters
Blower Furnaces�-
Gas Fired Boilers
Warming.Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
�� {
Floor Furnace ;•-'��,•_
Miscellaneous
;r IMW
NAME TYPE)
pp lance Fees ]
IF
inspected and Approved ..............:...i
.... _............_...-.......... "---
DATE. INSPECTOR
HOUSE GAS PIPING 5
Number of Outlets Size of Main _ '+
Gas Piping Fees
Tested and Approved ...... _-.�5'- -�
DATE INSPEC OR