2619 / 7,29a
LOT NO. /
FIAP IN FOR GAS PERMIT
NOV 7 . ���'
—CITY OFCUPERTINO
Date"((��IJ,d�1F A"'RER ":)iqo/F Permit No.�(O/%
Fee $ /Jo
Application is hereby made to the City of Cupertino fora 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.
u
C �
UseofPremises �/i✓6<f�E��oE✓G�E
Vn Owner l/�LrYi1LcA .F�J<O,Pr _ Address
By Address
Address �•��f. E/'fcr✓���C
CONTRACT00.� AGENT
Phone C� ;Oo Approved
PLUMBING INSPECTOR
Remarks (Check V)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters I ��
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
'Griddles
Steam Tables
Gravity Furnaces
• Suspended Unit
Floor Furnace
• Miscellaneous
, NAME TYPE
Appliance
Inspected and Approved ..............:...!. .
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets ,j Size of Main
Gas Piping Fees
Tested and Approved . ..l.. .- .� .'C. .. ............................................
DATE INSPECTOR