1777 LOT NO. Fz
N 0 e
® P LICATIO R APPLIANCE PERMIT
1 MAY 2119 4 OF CUPERTINO
Date �f�1 1 lBC��;+196..... Permit No.
V
Fee $ /
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 rode of the City
'\ of Cupertino, and all
/other
�laws applicable thereto.
Use of Premises Not`�
ID
r7 Ow tet/ _ Address
By' Address
G cONTR CTO AGBNr
(U Phone D Approved l/
J� PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Ciradating Heaters
Blower Furnaces
Gas Fired Boilers I II I
Warming Ovens
Percolators
Griddles II
Steam Tables
Gravity Furnaces I
Suspended Unit I II
_Floor Furnace I I
Miscellaneous I I u
NAME TY E) I I
I I II I
pp lance Fees
Inspected and Approved .:� .�.�. .� .t... ......
DAT. INSPECTOR