64190 858• Lily
Building Permit Confirmed ❑
Not Required
CITY OF SAN JOSE BUILDING DEPARTM NT
APPLICATIO FOR PLUMBING and/or GAS PIPING PERMIT
Date-.� .._IY.Cl...-------- 19-------- Permit No. - ... -- - .... ------------------
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 hereby claimed
by undersigned: as owner ❑ statement filed ❑
Undersigned attests that his State of California Contractor's License #
is in full force and effect and properly authorizes 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 manta so as to violate the workmen's compensation laws of California.
OWNER
ADDRESS,
USE OF BUILDING
FORM 260-30 (REV. 3/fi6110M
Signed .-- -------- -
-- --- ------ ------------------------------------------
858 Lily Priece
FIXTURES 00, FIXTURES MAIN DRAIN
Wafer 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 I 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
Drinking Fountains Survey
Permit Fee
TOTAL TOTAL FEE d-'D
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial No. lines Outlets Size
Rough Tested and Approved
Finish / _ ? /L G.��. By