100054 1 DSol ► LOT NO.
NO. AM SREBT
N APPLI ION OR GAS PERMIT
W Z ®IOGT L H �9H5 TY OF CUPERTINO
F a
Y LLO
3j Uate 196— Permit No. LO0 S- /
i LL CITY V
0 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
r and/or appliances in accordant with the provisions of the Plumbing Code of the City
U)
of Cupertino, and other laws licable o. , `
Use of Pr ises FI R 1 Ube& 1' e f�
00 !!� -- /�
3 Owner 0� MAC(4 Address A i AA ASr Q
0a
ZJ
z By Address
O CONTRACTOR, AGBNT
; 0
Z Ph '
u Z
W W
o fState License �► A - Approved /I
40
PLUMBING PSP^ v/
Remarks (Check ✓)
Type of Appliance Units Fees New I Replace I 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 GASJING
Number of Outlets Size of Main
Gas Piping Fees w�
Tested and Approved ................._.....,_..----- ---._.._................._..--"--
DATE INSPECTOR