1188 �OD�B LOT NO.
NO.,. ° �5e*i.w. F
® APPLI\ 'C' 11 R GAS PERMIT
'JAN g
CITY UPERTINO
. . fit •-. -
„., Date J� � p Tp :T _L Permit No. TS
CITY
OF CUpLRi IVlJ Fee $_c)?.d0 r
'0 Application is hereby made to the City of Cupertino for a permit to install gas pipes
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 thereto. 1
v
Use of Premises
7 . ^
v, Owner Address ^s
By •:Address10
CON CTOR, AGENT
Phone �• Z?_nE f�S� Approved — D
r �� PLUMBING -JSPECTO
yV:
Remarks (Check J)
Units Fees II New I Replace I Relocate
Type of Appliance
Gas Ranges
Wall Heaters
," II I I
G,as„Piates I
,Ci7r dating Heaters I I
:BI'bwer Furnaces 1 I I
Gis Fred Boilers I I II I
Warming,Ovens I I II I I
Percolators I I
Grid _ s' II 1
Steam Tables
AGravity Furnaces I I I I
3usrended,Unit I II
Floor.Furnace
Miscellaneous
NAME TYPE)
I I II I I
I I II I i
I I II I I
I I II I I
pp lance Fees
Inspected and Approved ..............:... ....................-----:----- .---------
DATE. INSPECTOR
HOUSE GAS PIPING
Number of Outlets I I Size of Main
Gas Piping Fees
_1
Tested and Approved . .. . .1✓ ...I. .. ......................................
DATe INSPECTOR