605 (2) 13
It
�; `= y ,"APPLICATION 1FOR GAS PERMIT
CITY ,OF. CUPERTINO
NO Date -t 195_. Permit No. O
I 'vo} CUPERTINO Fee $� .
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.
v
C
Use of Premises_
rn Ow
Address
CONTRACTO , AGENT
Phone Approve f i� TU C1i2T—
PLUMBING INSPECTOR
• Remarks (Check ✓)
' Type of Appliance I Units Fees II New Replace Relocate
Gas Ranges
`Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces _ ,I-
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
Appliance Fees ��'
Inspected and Approved ..............:
DAT P. ...!................INSP ECTOR ------.-------
HOUSE GAS PIPING
-Number of Outlets Size of Main
Gas Piping Fees
,Tested,and Approved /L/7. . ..
.......... ..................
DATE INSPECTOR
i I.