64166 8s8 LILY
Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
Date..V.C.1h-ir.L.....ZQ-------------------- 194.. Permit No—.��Z G C
'---"-------------------
The undersigned hereby makes application to the Plumbing Inspector of the City of San Jose
for a permit to install plumbing fixtures and/or pipes listed on the reverse side.
Exemption from requirement for State of California for Contractor's License is herebyclaimed
El undersigned: as owner statement filed ❑230 9%3
Undersigned attests that his State of California Contractor's License #
is in full force and effect and properly authorixes this application.
San Jose City Business License # O rAl -9 K
I certify the+ in the performance of the work for which this permit is issued I shall not employ
any person in any manner so as to violate the workmen's compensation laws of California.
OWNER I J � A(Z-P'c i E
ADDRESS B S S L I I Au C
USE OF BUILDING Sw t n+(�
0--�
FORM 28030 (REV. 3661 IOM
Signed--------_rv�
-----1 - Ly l '
858 Lity Haven PodI
FIXTURES FIXTURES MAIN DRAIN
Water Heaters Floor Drains -Sizef 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 WashersTrailer Space Size Material
Waste Disposals Swim Pool X401/1 FEES
Wash Trays Indirect Wastes Fixture Fee
Washing Machines Drywell - Main Drain Fee
Wo
T
I reat. Equi Backflow Preventer w Storm Drain Fee
Sinks Survey Wafer Sys. Fee
Dental Units Gas Piping Fee
Drinking Fountains Suryey
Permit Fee
TOTAL TOTAL FEE 7 0
INSPECTOR'S REPORT, ��. HOUSE GAS PIPING
Partial fllgrlbcNo. Lines Outlets Size
Rough Tested and Approved
Finish - By �'e A