51145 (3) CP2� o� y LOT NO,
5TH
VrAPR
N FOR GAS PERMIT
z 4 066I i OF CUPERTINO
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CITY OF CUPERTI I�.I b96 Permit No.
w w Fee $
o Application is hereby made to the City of Cupertino for a permit to install gas pipes
`o a and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
i m and/or appliances in accordance with the provisions of the Plumbing Code of the City
i w of Cupertino, and all other laws applicable thereto.
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0 „ Use of Premises
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3 Owne Address
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O CONTRAR, AGENT
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o f State License 23" " Approv
a/0� PLUNMING INSPECV
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
Testedand Approved ......_................ ...:..................--------.. ._........
DATE INSPECTOR