1626 ( eSiC(/ '4 • LOT NO. o
NO. �k .
PPLtCAlO FOR APPLIANCE PERMIT
r
, FEB 19 196 �!* OF CUPERTINO
'�- Date 2- /Y196-y- Permit No. (� _
CITY OF PER as—
Fees
o Application is hereby made to the City of Cupertino for a permit to install
N gas 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.
aUse of Premi
u
rX Owner , // ey,! ,t ti Address S A,�>t..w Ae _
By 9;Aj L, Address 2 76 7 - S<« RIoI
CONTRACTOR, AGEN
Phone T S'r�lr /4rQ
2-`{7- 3 z2- 3 z o� Approved
PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees I New Replace Relocate
Gas Ranges I II
Will Heaters
Gas Plates I II
Circulating Heaters I I
Blower Furnaces
Gas Fired Boilers
Warming Ovens I II I
Percolators I�
Griddles
Steam Tables
Gravity Furnaces II
Suspended Unit _
Floor Furnace II
ry /' la la-s-Il I
Miscellaneous
NAME TYPE I � I
lu I SII I
I I II I
Appliance Fees
Inspected and Approved ..
D/ INSPECTOR