2007 4 I 0,I LOT NO.
N nSTa. ;i '\\
IAUGAP �j �T `. FOR GAS PERMIT
;i f�" rCIVIF CUPERTINO
/+ U*OF C1-IP€R1!JWq odoo' 1
Date l,� �, Permit No.
W
Application is hereby made to the City of C Rhino o��$it to ms
and/or gas appliances as listed on the reverse sid ereoCfYand agre (�Q�nstaryl� id "pipes
and/or appliances in accordance,withlthe provisl_on0.yyotJ&e Plumbi�n'g Mde-o �the City
5
of Cupertino, and all other laws apYplicable thereto. •��:, �,=;, `'
CITY OF, CITEk��;l�'�h;;<c
. Use of Premises ��+r
SiOwner i Address'�Q/ r
( B Addres S�
CONTRACTOR, AGENT
Phone Approved
PLUMBING SPHet R
Remarks (Check ✓)
its_
Type of Appliance UnFees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates .I I •-`'• n. AI
Circulating Heaters �I
Blower Furnaces
Gas Fired Boilers I !i I•_
Warming Ovens %
Percolators
Griddles 11 1 - lfl
j Steam—Tablesl IL I 1 ( '71 V
Gravity Furnaces I I «I
Suspend•_d Unit I I II t"'
Floor Furnace I
I I II I
Miscellaneous
NAME TYPE)
I I II I I
I I II I
I I II I 191 �
II Il II I � =' I �l
pp lance Fees
Inspected and Approved ., ::;�%..',j;•.{y7., ---
D TP v.'INSPECTOi�g:' .s.
HOUSE GAS PI I
Number of Outlets Size of Main—' ' —
Gas Piping Fees I "�Lc•�_`-,g•f `.
— --
Tested and Approved ......................_I....-...........::$:"".;':-k.`... .....
DATE INSPECTOR