2781 •/D W� LOT NO. �v
Icy sTltEi41
-
AP fOLIC IWN FOR GAS PERMIT
/APR It X04 M ,
w i CITY OF CUPERTINO
O
f �
3 Y oF �/
LL (r+
<
Dat Tr:�1119� Permit No.
U
= LL tees /,SD
O Application is hereby made to the City of Cupertino for a permit to install gas pipes
o a 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 w of Cupertino, and all other laws applicable thereto.
W T
r
0 o Use of Prefhises
o a Ownf AddresirC/ =�4�
z
Z By Address x
�
CONTRACTOR,,
AGENT
39ti-3 .3
— z Phone
w z
w w
i o State License Approved
_U
PLUMBING INSPECTOR
1
1
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
Sugpended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS P1 ING
Number of Outlets \ I Nize of Main 3
Gas Piping Fees
Tested and Approved ....... 1� .`.... . .... ............................
D E \ INSPECTOR
\'J