1661 69 ` ` - / `. _ - LOT NO.
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APPLICATION�'FOR APPLIANCE PERMIT
I G 1�b4 :CITY OF CUPERTINO
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T ' 196..". Permit No.
Fee s -o0
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 bode of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises
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kS (
r'!S Owner�iN,Co. av� _ Address 4.Q�^� 1
ByVt,�'-U W41 'N` -� AddressA&�Ly
_ CONTRACTOR, AGENT
p_ Phone Z`, $` S APPtove
J" PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers ----
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit _
`Floor Furnace
GU
Miscellaneous
(NAME TYPE)
Appliance .od
Inspected and Approved ................ ..'.
...................-.... ........
DATE. INSPECTOR
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I 4tC) I}CX420t�j�(.
'NE- 5434- r