2804 '—?3(0 f F�Uir Pi LOT No.
ASP CAl N FOR GAS PERMIT
W
m ¢ APR 27 1964 OF CUPERTINO
Moo Y
� LL / G
o < Da .�O/d1 iu�rnTn�n,196L Permit No.��
a n Pee $li�—
x o
Application is hereby made to 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
i - and/or appliances in accordance with the provisions of the Plumbing Code of the City
¢ W of Cupertino, and at otheT laws applicable thereto.
a x
ao Use of Premises
bI*
o Ow Address✓r/D �' L!
z J / ,yJ
z B G Address �
! O y CONTRACTOR, AGENT
3 �
¢ Phon
N
w
w
oState Licens Approved
V PE IIKG IPISPECfOR
l
Remarks (Check ✓)
Type of Appliance Units Fees II 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