499 State License
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Remarks (Check ✓)
Type of Appliance I Units Fees II New Replace Relocate
'Gas Ranges . 1 I
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) I II
ApplianE-e-Fe-es -1 1 11 I 1
Inspected and Approved ..............:...I._.__................... ---_.-.._.......
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets 01l Size of Main
Gas Piping Fees
Tested and Approved .�........ .....................
DATE WSPECTOR