378 (2) LOT NO. ,_��_
NO. STLLLT
APPLICATION FOR APPLIANCE PERMIT
�� OF CUPERTINO
3�gDate �r , W.Y. Permit No. _
! J J D
p Fee$
Ic u f a e City of Cupertino for a permit to install
CE � fl— a
gas app lances as lis a on a 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?
z
In- Owne o_ Address
By -Address
\\ coNTLncro , ncLNr '�v
( 3Pt.one E.C' '� — ✓� 3 'Approve
` PLUMBING INSPB OL
Remarks (Check ✓)
Type of Appliance I Units Fees I New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters I ��
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
rSuspended Unit
Floor Furnace
Miscellaneous
NAME TYPE)
Appliance Fees
Inspected and Appro'ved/G ��..�. _.........'.._....................
DATP. INSPECTOR