1553Uo //
te„ i, 1 '1 - LOT NO /
NO. STREET
�Pf,LIF gIO� N FOR GAS PERMIT
OF CUPERTINO
- Oo Date t95_ Permit No. zJ
n CITY OF CUPERTINO Fees
Application is hereby made to the City of Cupertino for a permit to install gas pipes
and/or gas appliances az 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.
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Use of Premises / dLzz' c e
a
Z46 Ownerl!li�ZMo Aa.�f.a, �?`� Address�Qp
n
^r Address
CONTRAC]'OR� AGENT
Phone FiP—�'Q/// Approve
PL""'G INSPECTOR
Type of Appliance I Units Fees II
Remarks (Check J)
New Replace Relocate
Gas Ranges I�
I
WallHeaters
Gas Plates
Circulating Heaters I I II
1
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griaalee I I II
I I
Steam Tables � 1
��
Gravity Furnaces
1� 1
Suspended Unit 1
II
Floor Furnace I
II I
Miscellaneous
(NAME TYPE� i
II
I
�I I 1
Lance ees
pps n
Inspected and Approved......A....
�...... ......................
1DATPINSPECTOR
HOUSE GAIPING
Number of Outlets 1 a I Size of Main 1 1111
Gas Piping Fees
Tested and Approved.......................................................................
nATP INSPECTOR