51064 GAS I f JJf n�a K N4�L c PC LOT NO.
NO. ITREFT
CATION FOR GAS PERMIT
® �/g'i� CITY OF CUPERTINO
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3 V , S E P �65 196J Permit No.
= Fee S
o CITY Afhca�n 1PERIef f f ie to the City of Cupertino for a permit to install gas pipes
p and/or gas appplllances as listed on the reverse side hereof, and agrees to install said pipes
r and/or appliances in accordance with the provisions of the Plumbing Code of the City
< of Cupertino, and all other laws applicable thereto.
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0 o Use of Premises �«!J� �� �y�a L.
oa Owner � Address Z� p 04 e— 0(.
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z By �LU'E gtJE/11 �6tS Address
3 � q CON RA 70R, AGENT S'J�'
W Phony -lJfS- ��t'U
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ao, ISt.to License—`1y �'�-2 Approv
U I(N� -L' n G INSPECT /
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Will 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