51134 ig4 ,11 I r_-lM 'G�Q �\ LOT NO.
NO. ST ET [[
i° C ON FOR GAS PERMIT
m ` RUL
OF CUPERTINO
wa
o 29 1965 -iI
a _
° < Uate 196— Permit No.
3U TY of rl�p T N(�
W LL cl C'd qW ERTI b`th Fees
° hca n is b t e City of Cupertino for a permit to install gas pipes
`o and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
r r and/or appliances ' a ordance with the provisions of the Plumbing Code of the City
i w of Cupertino, and I of er laws applicable thereto.
u I
0 o Use of P�es
it
3 Owner • ^Q2 Address
zJ
By
z Address S
°
TRACTOR, AGENT
`T.ter
/— m Phone
u z
a0
State Licenseu�� 3 �3 Approve
Ag&
— 0* PLUMBING INSPECTO
Remarks (Check ✓)
Type of Appliance Units Fees New 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
Floor Furnace
Miscellaneous
(NAME. TYPE)
HOUSE GAS PIPING
Number of Outlets Size of Main
Gas Piping Fees
Tested and Approved . ......_....._...---- ..._...._......__..___—...............
DATE INSPECTOR