77421 873 Lily . � �
Building Permit Confirmad Q' '
No} Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
�� Dafe-------..l....�.�.�...---------------- 19G8 Permif No.------../...L._�Z�..............
- _ Tho undersignad hereby mekes applica}ion lo tha Plumbing Inspecfor of }ha City oi $an Jose
for a permiT io ins}all plumbing (ixfures and/or pipes lisfad on ihe revurse sida.
. Evamplion from raquiromenf for Sfa1e of California for Coniracfor's Lit¢ns¢ is hareby claimad
by undersigned: � as ownar ❑ slatamen} filed �1 r� r�
Undersigned a!!e:}s fhe} his $4efe of Celifornia Coniraclor's license # � dZ/ �/
' is in full iorce and effect and properly auihorizes fhis applica�j/ 2 ��
$an Jose Ciiy Businass License #
' I terfify iha} in fhe performanca of Iho work for which ihis permi4 is issued I shell no} omploy
' any person ln any mannor so as fo violate t�he-w7orkmen's compensa}ion laws of California.
� OWNER � � �f�d So r�
ADDRESS � � 3 ��� ��Gr
' ' USE OF BUILDING �� / �
Signed ..... -- - ........ .. - - �..--- ....
FORM 2B0-30 IOM 1/6B �
.. /�L�%�elt����/n>C
873 Ir� Lily _
/
PIXTURES FIXTURES MAIN DRAIN
Wafer Heafers Floor Drains Size Material
Wafer Closets Hoppers To To Septic Tank
Bath Tubs Sand Traps RAIN WATER DRAINAGE
'�Showen Urinals Size Mnterial
Lavatories Area Drains To Curb To Main $ewer
Kifchen Sinks Water Leaders WATER SYSTEM
Dish Washers Trailer Space Size Material
Wasfe Disposals Swim Pool FEES
Wash Trays Indirecf Wasfes Fixture Fee
Washing Machines D�ywell Main Drain Fee
Wafer Treaf. Equip. Backflow Preventer Storm Drain Fee
Sinks Survey Waler Sys. Fee �
Denfal Unifs � _ Gas Piping Fee 3 '
Drinking Fountains Survey
Permif Fee 2
TOTAL TOTAL fEE o'1, .�
INSPECTOR'S REPORT HOUSE GAS PIPING
PaMial No. Lines / Ouflets Size
Rough y
Tesfed and Approved R
F�msh BY J
i .�P