100031 NO. STREET
APPLICATION FOR GAS PERMIT
CITY OF CUPINO
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3 ' I to 196_ Permit No. w V d 3/
U Fee S 5--�
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Application is hereby made to the City of Cupertino for a permit to install gas pipes
'o � rpp ( pit the reverse side hereof, and agrees to install said pipes
`a51cP/br a Ifiani I c del with the provisions of the Plumbing Code of the City
mOf Cupertino, and all other laws applicable thereto.
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Use of Premises
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3 Owner -� e✓ ' ` // Address
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ONTRACTOR, AGENT— z Phone.
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ao State License "2� �G S Approved—
I D. BENEVICH
- 0 PLUMBING INSPECTOR
Remarks (Check d)
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 1/s
Testedand Approved ._.............__.............................._........ .........
DATE INSPECTOR