2691 LOT NO. ,
CJS /No. ET 4 I .N FOR GAS PERMIT
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® CI a OF CUPERTINO
(JAN 3 U 1964 /y
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0 ' Date 196— Per
No.
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a r'T�r ( C�UPE�RTLR10 Fee$
ApPli i iion here y ma e to the City of Cupertino for a permit to install gas pipes
o . and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
r and/or appliances in accordance with the provisions of the Plumbing Code of the City
<w of Cupertino, and all of laws applica thereto.
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LL Use of Pr ses
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> 3 Owner
z By6P/ Ut JC--)F (?,n Wtt\ddDess �g�T STSChIE'r^lU (7
° CONTRACTOR, AGENT
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01 State License T Approved
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n^ PLUMBING INSPECfO
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
(NAME. TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
(jas Piping Fees
Tested and Approved ../.- /�.. .. . . . . .................
DATE INSPECTOR