51028 '?-d 6 / C"'- LOT NO.
.NO. STREET 61
p1 TION FOR GAS PERMIT
` ?(A1GQ2 :jqr65 OF CUPERTINO
zO °LL° jDate 196_ Permit No.
3�
w Fee S
° CITYPIiO& Ce __ t�athe City of Cupertino for a permit to install gas pipes
o a and/or gas appliances as este on the reverse side hereof, and agrees to install said pipes
> and/or appliances in accordance with the provisions of the Plumbing Code of the City
z ou Cupertino, and all other laws
z ) f CP applicable thereto.
u I
w f
Use of Premises
00
3 Owner r Address
? z By 1 �Addressj
3CONTRACTOR, AGENT ,PCJ
— m Phone ,�?4� 7,�"LilJ /✓
a State License j �� / �' Approved
_ 0 PLUMBING INSPECTOR >
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 '
Tested and Approved ___...._........._ ......__.............__......._...........
DATE, INSPECTOR