2622 4 n 1 - y
LOT NO.
NO. TREET r0
APPL`ICI� NX
TION FOR GAS PERMIT
W z /N OV 8 1963 ddb OF CUPERTINO
s �
, 0
3i LLa Date-
y/ 196-3 Permit No. ea
tUC CUPERF
Fee $ 4�
//' 60
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
'zm and/or appliances in accordance with the provisions of the Plumbing Code of the City
< of Cupertino, and all other laws applicable thereto.
w
v x
of Pr
o jJ77 / al�'
Y m �j
3 Owner Address_�o 10 �0
? z B• 7� /�- N ��� Address
� o y coNTRAcr ,AGENT
3 � 9
— z Phone.
w w
n s State License a Approved
<0 7
PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees II New I Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
•"arming Ovens
Percolators
.j'iddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
(NAME TYPE)
HOUSE GAS PIPING
Number of Outlets I Size ofi Main
Gas Piping Fees I I
Tested and Approved ._ r. . .�. ... . .�_ .t t.��_............ ............
ATE 1 INSPECTOR