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Yt - LOT NO. ,.
NO -! !STREHT,
ICAT ON FOR GAS PERMIT
99E;I 'OF CUPERTINO
Date t/ice 99 �g59` 195_ Permit No.
5�
-r. �RINO Fee $
Application �sLberebyrmad 'to he 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.
� v
.12 Use of Premises
A Own` A rd ed ss-
}t. By Address
r N T , AGBN
t Phone ApproveWA
PLUMBING rN5ICF{
. t
,. Remarks (Check ✓)
Type of Appliance I Units Fees II New I 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 II
Floor Furnace
Miscellaneous � � i� � 1
(NAME TYPE)
pp lance Fees-
inspected and Approved ..............:...!........_.....................................
.
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main
Ga4 Piping Fees
--'--
:Tested and Approved +�. Cyd...�. ........................
DATE / INSPECTOR