1150 NO. �STRagT
_ LOT NO. � I
OR
ft
PEICATOOl' FOR APO'LIAkdk PERMIT
if FEB 2 81969`A&F CUPHRTIN' 0
Date ��2 tK �E69�6- 3 Permit No. ( � V
E6 Fees
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 rzde of the City
of Cupertino, and all Other laws applicable thereto.
u
Use of Premises��
ti Own 6'W""` _ Address n
By Address2
CONTRACTOR, AGENT
Phone d 2 3 K 1 Approved
• PLUMBING INSPE R
Remarks (Check ✓)
Type of Appliance Units Fees II New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces 1.3 11
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Gravity Furnaces
Suspended�Unit
Floor Furnace
M;pcellaneous
(NAME TYPE) Til
pp lance ees —�
Inspected and Approved ............... ..'.................................
..............
DATE INSPECTOR