2614 LOT NO.
NO.
® APPLIC � tON FOR GAS PERMIT
i `— �,� I rY OF CUPERTINO
Y o 1 NOV 1 1963 u'''
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3 a Date dr z'9 196 Permit No.
CITY OF CUPERTFee$
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
Z a 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.
SLL Use of Premises �- RESIDENCE"
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3 Owner Address 6uPEWii.✓a
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z B �jCOGJLGI/ Go Address Mr^/ /�Eid
O y CONTRACTOR,AGENT -
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— w Phone��o7 SSJ�
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ao State License /6699 , Approved
PLUMBING INSPECTOR
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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 _
FIgor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets 5ize of ain 1 ¢
Gas Piping Fees
Tested and Approved ..... r.7l. ......!..'�.. ........................
D TE , INSPECTOR
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