1588 LOT NO. 127
NO(Y.12 �S711B8Tj
APPLICATION FORM APPLIANCE PERMIT
LA ' DEC 9 196,b*48'' CUPERTINO ! f/
Date n Tv4 fDeoni mrnT•,�19G3.. Permit No.
v t t— UN Ltl -
OD Fee 5.�
N
00 Application is hereby made to the City of Cupertino for a permit to install
O
1igas 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 R e s
2 Ward Crump Dev P.Q. Box 634
w Owner _ AddressCupertino —
.9an Carlos Sht Mtl Address 779 Old County Rd.
Phone 591-2A I
CONTRA6(T)
"cervr Approved S. C
d� I PLUMBING INSPECTOR
Remarks (Check ✓)
'Type of Appliance Units Fees II New I Replace Relocate
Gas Ranges II 1
Wall Heaters
Gas Plates II I
Circulating Heaters I 1 II I 1
Blower Furnaces I 1 1.06 x 1 1
Gas Fired Boilers
Warming Ovens 1 1 1
Percolators I 1
'Griddles
'Steam Tables 11 1
Gravity Furnaces
Suspended Unit
Floor Furnace
I I II I
,Miscellaneous i1 1
(NAME TYPE)
nl
—Qutl etg I.I. I 1 2.7511
Comb Vent A.00J1 I _
I I II I
I
Appliance Fees
Inspected and Approved ... . .. .............................
DATE INSPECTOR