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NO.
N ,PPL 1G �TaION FOR GAS PERMIT
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o OF CUPERTINO
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0 aDale M Permit No.
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CIT OF CUP I`1I11 Pee $ V15-0
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� Application is hereby made 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
i m and/or appliances in accordance with the provisions of the Plumbing Code of the City
a of Cupertino, and all other laws applicable thereto.
w Use of Premises
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0 3 Owne / i Address
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zBy Address
o / CONTRACTOR,AGENT
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oState License Approved
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PLUMBING INSPECTOR
9
Remarks (Check ✓)
Type of Appliance Units Fees I 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 PIPP,G I'
Number of Outlets ize of Main I -1 Ii
Gas Piping Fees /
Tested and Approved
OA I fNSP ECTOR