78019 1b41 .lames Town
Building Permit Confirmed El
Not Required
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
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Date..--/'D----�----�--J--- .............. 19.�.... Permit No.---..�.d.--�--�--(�-------------------
The undersigned h eby ekes application to the PPI uJ^6'ing Inspector of the City of San ,lose
for a permit fo imf
p m i' nd/ r py jsSj�d/6n the reverse side.
E.emption from to C rnm r Contractor's License is hereby claimed
by undersigned: as owner statement filed El
Undersigned attests that his State o a rn'a C��yptr tops Li _qhs{{'
is in full force and effect and properly a s th,e C//—/
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 man r so as to 'olate the workmen's compensation laws of California.
OWNER
ADDRESS
USE OF BUILDING
Signed.. .�.'t...' ;.. -' -- ---- --- ---- - -----------------
FORM 280-30 IOM 1/68
I AAA .Tomas Tnwn, Stewart
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 SizeMaterial
Lavatories Area Drains To Curb I 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 -3ZS
Drinking Fountains Survey
Permit Fee 7,
TOTAL TOTAL FEE 2 ,3
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial No. Lines , Outlets Size /747
Rough Tested and Approved
Finish By -
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