69402 795 �#d2ks.tDii�
Building Permit Confirmed rpt /
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
. 1967 No �/L
Dafe..
a 2—
__ . - ----- ------------------- 9 ---- �-------- ---------------.
_.
The
undersigned h eb}'�,t,�,r� a �,e umbing Inspector of the City of San Jose
for a permit fo9insial p4MN fi as a or pipe listed on the reverse side.
Exemption from requirement for State f California for Contrac orls_License is hereby claimed
by undersigned: as ownef n4 fi ❑ /�//
Undersigned attests that his State of Ca I(ornia Contractors Licens� / Z-0
is in full force and effect and properly authori es this aapplication.
San Jose City Business License # —! d
I certify that in the performance of the work for which t is ermit is issued 1 shall not employ
any person in any m nor so as to vi late the workmen's compensation laws of California.
OWNER- -�Q—I-
ADDRESS '��n /���/grc-� Ul"1 G �� EN
USE OF BUILDING.(L7I1�
FORM 200-30 (REV. 3/661 IOM
7995 FiDLk9ttoda F&W
FIXTURES FIXTURES MAIN DRAIN
Water Heaters / Floor Drains Size " Material
Water Closets 3 Hoppers To To Septic Tank
Bath Tubs and Traps 1 SRAIN WATER DRAINAGE
Showers r2 Urinals Size /41 Material _
Lavatories Area Drains To Curb To Main Sewer
Kitchen Sinks / Water Leaders WATER SYSTEM
Dish Washers Trailer Space Size n Ma
Waste Disposals Swim Pool FEESterial
Wash Trays f Indirect Wastes Fixture Fee �,pp
Washing Machines / Drywell Main Drain Fee
Water Treat. Equip. Backflow Preventer Storm Drain Fee .pp
Sinks Survey Water Sys. Fee
Dental Units 5'1,vkl. Gas Piping Fee
Drinking Fountains Survey
Permit Fee cy a
TOTAL / TOTAL FEE
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial / ? L '7 No. LinesZ Outlets Size
Rough 2Tested and Approved fli,r/G 7
Finish p " 'Gl �' By rf r'� GioA�rin