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�I ATIVN, FOR GAS PERMIT
z i CIT OF CUPERTINO
x :/MAR 2 1963 d
¢ - �r�/7
° 'a Date 196 Permit No.
LLCITY OF CUPERT`O Fee$ g2• 70
° Application is hereby made to the City of Cupertino for a permit to install gas pipes
o a and gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i < and/or appliances in accordance with the provisions of the Plumbing Code of the City
a w of Cupertino, and all other laws applicable
thereto.
W Use of Premises
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3 Owner�O Address Z6ZZ— 1LL L[2c.e
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0a State License Approved
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Remarks (Check J)
Type of Appliance Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters I
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit �
Floor Furnace I
Miscellaneous
(NAME. TYPE)
HOUSE GAS PIPING
Number of, Outlets Size of Main
Gas Piping Fees ,
Tested and Approve! ZtA
f INSPECTOR
State License/2/ 40'00 — /D
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