1665 107 LOT NO. S __
N � T
® P LICATI0N OR APPLIANCE PERMIT
tr�uR 5 1964W OF CUPERTINO
Datqw`�t3hrnT-L& 196.y Permit No.Ur LIU[
N Fee S
0/ as
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 rode of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises '1)w
h Owner—
/��� �"f1 °/( _ Address 2 75
L� Address—
Phone
By e T1��OF Address_ / ��
/� , CONTRACTOR, AGENr
Phone t/� �i�i S 24 Approved
PLUMBING INSPECTOR
Remarks (Check ✓)
Type of Appliance Units Fees I New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters I I�
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit _
Floor Furnace
Miscellaneous
NAME TYPE)
pp�Fees
Inspected and Approved ..... _.................._. .......................
DATE. INSPECTOR