81356 1123 Elmsford Drive
Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING
y and/or GAS PIPING PERMIT
Dafe�.._.bC.�..d....-----------------_-- 196-./.. Permit No............!�.�J..SrL2------------
The undersigned h i o o e /h-f�J�g Inspector of }he Cily of San Jose
for a perm if fo instal * u n r iGrfiaE on }he,reverse side.
Exemption from require rut for State of California for Contractor's License is hereby claimed
by undersigned: as owner/p��l �f fi
Undersigned attests that his Stale oV[! arnie q ctFr stidanfj ❑
is in full force and effect and properly �horizes this application.
San Jose City Business License #
I certify that in the performance of the work for which this permit is issued I shall not employ
any person in any
pruner so as to riola}e the workmen's compensation laws
of California.
OWNER,, ��EJC 0 (w�f)' ���J ! I?
ADDRESS Rh
USE OF BUILDING C
20030 10-66 Signed
1123 Elmsford Drive
Smiley
FIXTURES FIXTURES MAIN DRAIN
Water 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 ols 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
TOTAL TOTAL FEE
INSPE TOR'S REPORTPartHOUSE GAS PIPING
Rou'hl No. Lines / -
g _ .�� Outlets Size
Finish Tested and Appr ved —�
- B _
Y