2760/10� 1 1/�/I1 t�t l �/�!` LOT NO. Tl 1 a
No. eat Pdlew.ild
`APP IL CATlO FOR' APPLIANCE PERMIT
y� A - OF CUPERTINO
k ? -- �U f �
Date a�?[+I 1ory 196::.., Permit No.
`t�U(p"CiS 166 Fee t
Q Application is.hereby made to the City:of Cupertino for a permit to install
gas appliances as listed on the reverse side hereof, and agrees to install said
appliances in accordance with the provisions of the Plumbing r ode of the City
of Cupertino, and all other laws applicable thereto.
e
Use of Premises
8
65 -Owner Rousseau Org. _ Addres M t. Sf, 9_.
779 OLD C&,W-4c5,AVENr
RAiIA-
kfype =ofApplianceM ''Units Fees
Remarks _(Check V -W-,
I New, Replace Relocate
,Gas -g -e -s
_N
Will 4
Gas Plates
CirculalinFgjHdFaters
;,Blower 136—Fraces 1
IIx I
GB F,:jffdAlLojIers
11 1
ns
117-1
'Percolators I I
it
GriddleiQAUj
aG r a _vii y F r nac
IS,Ssv e ed eld' U n i tE
,p!Ide
Floor Furnace
Miscellaneous
(NAME TYPE)
pp Fe—Vi-e—si
Inspected and Approved qW1114v ................. . .........
DATE ��JNSPECTOR.