75245 42 1123 Elmsford
Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR, PLUMBING and/or GAS PIPING PERMIT
May 22 68. �J��.-�)
Date ----- - y- ..... ........_.... .. 19.... . Permit No.. -(. - -- ... - - -
The undersigned hereb makes application to #h¢ Plumbing Inspector of the City of San Jose
for a permit io ins#all /I m n f' fi / p� gs 1' the reverse side.
Exemption from regal en /or a e Ca�r�� nfrec+or's Licensee is hereby claimed
by undersigned: as owner ❑ statement Filed .{16217
Undersigned attests that his State o� alif rnie Confr ##- 's2' en �
is in full Force and effect and properly ut s Phis a
San Jose City Business License $k
I certify that in +h' performance of the work for which this permit is issued I shall not employ
any peison in any manner so as to violate the workmen's compensation laws of California.
OWNER Donald Smiley —
ADDRESS 1123 Elmsford Drive
USE OF BUILDING Residence
0U / &n
- ... -
FORM 260.30 (REV, 3/e61 IOM Signe .......... . -
1123 Elmsford Culligan
FIXTURES FIXTURES MAIN DRAIN -
Water Heaters Floor Drains Size Material
Water Closets Hoppers To 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 FMaterial
Waste Disposals Swim Pool FEES
Wash Trays Indirect Wastes Fixture Fee
Washing Machines Drywell Main Drain Fee
Water Treat. Equip. 00 Backflow Preventer Storm Drain Fee
' Sinks Survey Water Sys. Fee 1.00
Dental Units Gas Piping Fee
Drinking Fountains Survey
Permit Fee 2.00
TOTAL 1.0 TOTAL FEE 4.UU
INSPECTOR'S REPORT HOUSE GAS PIPING
Pallial No. Lines I Outlets Size
Rough .z �� Tested and Approved
Finish 01,