51118 (2) O , LOT NO.
?(AUGTREET
�I ION FOR GAS PERMIT
h ` / I gl[CY OF CUPERTINO
°
17 1966
� a _
Y
R
0 ,
Dare 196_ Permit No.
3u
i4 CIT [ /�'Ip[ Pee$
° l.�t A�iph�lion4}ltIFr26$TId�4A 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 t e provisions of the Plumbing Co f the ity
i m of Cupertino, and all o er law p le hereto.
u I
w �
Use of Premi
Oo
3 Owner fi 7/� -/r' he Address /C7 14/ J� fr7"7'- • ILI.
Z J
� z By'�fi'Nri`/.n,ri4 OLS Address' o S (�oFlHr�c'i.7t�•
° CONTRACTOR, AGENT
3 N Phone
Y L 4l V 7 tr s-G
ao State License'y. `�° 7 Approv ' Ili
PL OINC INSPECTOR v
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 PIPING
Number of Outlets Size of Main
Gas Piping Fees
Testedand Approved _................_._.,.... ._..................................._..
DATE INSPECTOR