51167 (2)11091 1 Bubb Rd, 3
LOT NO.
NO. STREET
„ APPILIIC4T FOR APPLIANCE PERMIT
Z ® }� OF CUPERTINO
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0 U Date 1 N t — Permit No. -J—ZZ(,
W Fee •$
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0 fyppl o;ejI �[��`�j'Y��{��j� e to the City of Cupertino for a permit to
o a i a Aga pl Cs l 11lteon the reverse side hereof, and agrees to
i a install said appliances in accordance with the provisions of the Plumbing
Code of the City of Cu ertino, and all other laws
< = P applicable thereto.
4 LL Use of Premises Residence
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>0 Owner Ditz rr2ne Address P,G. Box 509 S, J,
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STATE CONT ACTOR'S
o °s State Licensed Approved
U� �� PLUMBING INSPECTOR
Type of Appliance Units Fees
Remarks (Check ✓,
II New Replace I Relocate
Gas Ranges
I
Wall Heaters
Gas Plates I I
II I
Circulating Heaters
Blower Furnaces
Gas Fired. Boilers
Warming Ovens
Percolators
I I
Griddles
Steam Tables I
II I I
Gravity Furnaces
Suspended Unit
Floor Furnace
I
II I
Miscellaneous I
NAME TYPE) I
Ill 12.1511
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219.0011
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pp lance Fees
Inspected and Approved .............
DATE INSPECTOR