100022 (2)oki I I •v • l LOT Nn.
NO. STREET
m APjPLICATION OR GAS PERMIT
p < LE LC-
zY OF CUPERTINO
a° ? (Nov - 4 1966 � la o :Z 2
0 , Uate 196_ Permit No.
U
oITS/ nr r1mynjd. to
Fees
CApplicahpn is.hereby_made ro the 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
> and/or appliances i ccordance with the provisions of the Plumbing Code of the City
i w of Cupertino, and o er laws applicable thereto.
u I
,. Use of Premises
00
3 Owner Address
o < p
z By; {l.®L KAVA &r0o�' .CA ulI Address 2661 SOW— QuXGuer
O CONTRACTOR, AGENT
3 X
— <m Phone 2cy,
� z
a U�e_State License Approved
PLUMBING INS R t/
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges 4
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)
AGM GAS
HOUSE GAS PIPING f 00
Number of Outlets Size of Main
Gas Piping Fees
Testedand Approved . ..............__....,.._.__............................__.......
DATE INSPECTOR