440 (2) LOT NO.
NO. STREET
_ APPLICATION FOR APPLIANCE PERMIT
"' :�'.• CITY OF CUPERTINO
3 'Date 196..... Permit No. 440 _
�Sb
\C1 Fee Z
1+ 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
�h appliances in accordance with the provisions of the Plumbing rode of the City
of Cupertino, and tther laws applicable thereto.
Use of re ises ���\\CI ,
u
r75 Owner NM2& Address
`ki
By Address
CO O0., AGEN
Phone Approve
PLV MEIN NSPECT R
Remarks (Check ✓)
Type of Appliances i)Units Fees II New I Replace Relocate
Gas Ranges
Wall Heaters I I I
Gas Plates
$_rculating Heaters 1 1 1
t lower Furnaces
'� Fired Boilers
y rmin Ovens ♦ 1 I
Pa4cp,ldolfs I 1 11 I
files I I I i
am Tables 1 II
Gravity Furnaces I I
Suspended Unit s' II—
Floor Furnace v
Miscellaneous 1 it
NAME TYPE)
I I III
I I IF
I
I I II I
I I II I I
pp lance Fees / ��—
Inspected and Approve .. ... ...................................
DATP INSPECTOR