671/ v 671 �C u �c rG« �✓ .. .
NO. STREET
LOT NO. S�
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5-APPLICATION FOR GAS PERMIT
i �' �-� TY SOCIP CUPERTINO
i (,T
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Date t93_ Permit No.
5a
CITY OF CUPF.RTINn Pee $
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.
Use of Premises
Owner
V497. 5{eva CeW'UORSAVR&a, G.
Phone
Address
Address
Approve
PLUMEI G INSPECTOR
Type of Appliance I Units Fees II
Remarks (Check d)
New I Replace Relocate
rpas Ranges I I
I
Wall Heaters I
I
Gas Plates I I II
Circulating Heaters
Blower Furnaces
Gas Fired Boilers I II
Warming Ovens I I I
I I
Percolators
I I
' Griddles
St Th—tjables
Gravity Furnaces
I I
Suspended Unit I I
II
Floor Furnace
I
I I
Miscellane- ,
NAME TYPE)
I I
II I I
I I
II I I
I I
II I i
I I
it I I
pp Iance Fees
inspected and Approved ........... .:..................................................
.
DATP
HOUSE GAS PIPING
Number of Outlets I. I Size of Main I
.Ga1Piping Fees I I
Tested and Approved ... ......... ......... ...I...............................................
DATE INSPECTOR