1662 / V // / I_ V\• �Y'Iv,tKi V "'�I Y �c-i jpT NO.
I APPLICATION tOOR APPLIANCE PERMIT
CITY OF CUPRTING `J
D� W 1 - Pt No.
_ ,;
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 slid
appliances in accordance with the provisions of the Plumbing rode of the City
of Cupertino, a d alld all oth I I b t Ie eto.
Use of Premises 7/ �.
8 % v-
in Owner '�' — Address
B Address 1412 Imo–
C TRACTOR, AGENT
90 Phoneme q.2 • '2O 3 Approve
PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance I Units Fees New. Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates'
Circulating Heaters
Bjower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles -
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnaceim
Miscellaneous
NAME TYPG�
1 4
Appliance Fees
Inspected and,'Approved ..... ' ..: _.....................................
�DATE /� INSPECTOR