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PCATION FOR GAS PERMIT
® OF CUPERTINO
Dat 195_ Permit No.
[ (f����� ppTT n(� Fee $ a
041icobn i3hf�rK65li�ythe 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.
Use of
./.' /x-- 4
. fONTRACTOR, AGENT
Rt 979oy
io
Address �N e57�
Address
1 APPr e
PLUMBING INSPECTOR
of Appliance
Units Fees I
Remarks (Check .1)Type
New Replace Relocate
Gas Ranges
Nyall Heaters
Gas Plates = II
Circulating Heaterse' _
Blower Fufnaces.
Gas Fired Boilers
Warming Ovens
Percolators
l
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
II
Floor Furnace
Miscellaneous
NAME TYPE) I
!'
I I
II I I
p�Fees
Inspected and Approved .....
...............................................
INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size ofN)ajpj
Gas Piping Fees
Tested and Approved 1) �r.`�_�..... ..
9 TE INSPECTYIA � _