1545 A0�2Q I O J may}
0 •l CC/LGC�C 1• LOT NO.
NO. 5
FfRGAS PERMIT
LAR. s �T7i Z ERTINO
p� Date fKO Permit No.
�}
� Fee $_.rX� �
Application is hereby trade to the City of Cupertino for a permittoinstall gas pipes
I 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
C1 of Cupertino, and all other laws applicable thereto.
u
O
:.a
Use of Premises
Owner Address &I AAA e
n e
/`[spy !" Address
/ NTRACTOR, AGENT
Phone C.e- /// ' Approved
PLUMBING INSPECTOR
Remarks (Check V)
Type of Appliance I Units Pees II New I Replace Relocate
Gas Ranges I
Wall Heaters I I I I
Gas Plates I I II I l
Circulating Heaters
Blov er Furnaces I I I
Gas Fired Boilers
II I
Warming Ovens .
Percolators
Griddles
Steam Tables I I I
Gravity Furnaces I I
Suspended Unit
_Floor Furnace I
I' II
Miscellaneous
(NAME TYPE
I I II I I
I I II I I
I I II I I
Appliance Fees I I I
Inspected and Approved ..............:...
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets I I Size of Main
Gas Piping Fees
_J
Tested and Approved ................
ATE INSPECTOR
>
0
\ � � / � .
4-1
. \ � � � �
§ / z
\ �/ 0
'0,
n M%