84749 LL40. Derbyshire Drive
Building Permit Confirmed 1:19
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING�JPERMIT
Date......— Lz----f.ta—"-'._ 19.fo-.F.. Permit No...9...F-.�/.7-..:/.---q-----------------
The undersigned here k s io f spec}or of the City of San Jose
for a permit to install p m i ur e s the reverse side.
Exemption from requi emen r State f California for Contractor's License is hereby claimed
b undersigned: s owner ❑ statement filed
y Undersigned attests that his Sfaf o aliforni Con}rector's License # OA
is in full force and effect and prop u} orizes a ar
San Jose City Business License �f
I certify that in the performance of the work for which this par it is issued I shall not employ
any person in any manner so as to violate the workmen's compensation laws of California.
OWNER_VA ILC-o S)-')
ADDRESS
IIL/O 7EA6Y S NiRC 7) R Lot No.
n
USE OF BUILDINGa
28030 Aug. 69 Signed .
CLR(/�.� - W<-C('- /a"'""----"'
LL40 Derbyshire Drive Ace PLumbing Serv.
FIXTURES FIXTURES MAIN DRAIN
Wafer Heaters Floor Drains Siie Material .
Water Closets Hoppers To I To Sepfic 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
Wafer Treat. Equip. Backflow Preventer Storm Drain Fee
Sinks Survey Water Sys. Fee
Dental Units Gas Piping Fee
Drinking Fountains Survey
Permit Fee ,Z, 0C)
TOTAL TOTAL FEE ?, ,o
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial
Rough No. Lines - Outlets Size
Tested and Approved
Finish ^U7o- B
Y