2379 'r AGREE I WILL NOT'VIOLATE ANY OF THE WORKMEN'S'`
COMPENSATION LAWS OF THE STATE OF CALIFORNIA"' `
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Remarks (Check J}. y
New Replace Relocate'
Type of Appliance Units Fees I
Gas Ranges
'Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas •Fired Boilers
W
Ovensslesrnaces Unitnace
Miscellaneous
NAME TYPE)
HOUSE GAS PIPING
Number of Outlets ( S'.e of Main /'•
Gas Piping Fees �16U1 '
�\
Tested and Approved ........L.Z. ..... .. .. ... . ..................................
DAT INSPECTOR