77128 914 Blazingwood
Building Permit Confir ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPART T
APPLICATION FOR PLUMBING and/or GAS PIPING PER C)
-71 Da+e--------- ?-�------ 19W Permi# No. ---Z- N
The undersigns a eb ke pis f e bin I r of fha City of Saose y
for a permit to i all n t / Fp li on a verse side. ++
Exemption fr ' a n or L ni or ontracfor s License is hereby ad�
by undersigned: as ownerstatement filed .3
Undersigned attests that his State of California Confracfor's License y /.9�3— �7
is in full force and off and,properly out rixe fhis a lice ' Q'!1
San Jose City Bus' as >µr (�
I certify fha4 in te o which s p issued I shall no+ mploylal
any person in any ner as
o Folate the workmen's comp etnnon laws of California.. 9
OWNER_A.- /i� 1 DeRA01V [n
ADDRESS ��7— - --4Z ���O d Z
USE OF BUILDING
FORM 20030 IREV, 3/861 IOM Signed J �n� " (�'
�
9Ta ^nn Renye- _
FIXTURES FIXTURES MAIN DRAIN
Wafer Heaters Floor Drains Size Material '
Water Closets Hoppers To I To Septic Tank
Bath Tubs Sand Traps RAIN WATER DRAINAGE
Showers Urinals Size Material
Lavatories Area Drains To Curb To Main Sewer
Kitchen Sinks Water Leaders WATER SYSTEM
Dish Washers Trailer Space Size Material
Waste Disposals Swim Pool FEES
Wash Trays Indirect Wastes Fixture Fee
Washing Machines Drywell Main Drain Fee
Water Treat. Equip. Backflow Preventer Storm Drain Fee
Sinks Survey Water Sys. Fee
Dental Units Gas Piping Fee
Drinking Fountains Survey
Permit Fee a--d
TOTAL TOTAL FEE 0-0
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial - No. Lines Outlets Size
Rough - Tested and Approved
Finish By