2716 O ✓'// �--I� /lV/!/ .V C LOT NO.
STREET
�APPH TION FOR GAS PERMIT
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z SCI t F CUPERTINO
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3u Date 196— Permit No.
W , Fee $
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App�i alion�ist her�b�jmmad�to�he 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
and/or appliances in accordance with the provisions of the Plumbing Code of the City
<� of Cupertino, and all other laws applicable t ryem�
LL Use of P mises
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3 Owner Address��l�
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CONTRACTOR, A ENT
3 < Phone Ut 7 7 7,1
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w z a Licens D8 3 6/ Cr5> - Approved State 156�-44f
-U PLUMBING INSPECTOR
Remarks (Check J)
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 _
Floor Furnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved , 'tr �.'T.. . ...X............................
DATE INSPECTOR