47905 CITY OF SA_N_ JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
i
Dafe ..... .......................------ --19...... Permif..No. 4:7 J ......... ..............
The undersigned hereby makes application to the Plumbing Inspector of the City of San Jose for a
permit to install plumbin i• d r isle on h� v de hereof, and agrees to install
said fixtures and/or p enc !h 1 pre a on a rlicls VIII, Chapter 2, o/ the San
Jose Municipal Code, and all ter laws applicable thereto.
I certify any
in the so as mance of the work f .n%this pe6m/IOCK�nyliempley any
person in any manna so m to violate the workm n's mp//a��mati ��j``y�
. OWNER
ADDRESS
USE OF BUILDING >r
Form 280-30 Signed ,---......-----...........................-----......................--......._.
FIXTURES FIXTURES MAIN DRAIN
Water Heaters Floor Drains Size Material
Wafer Closets Hoppers To 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 Trailer Space Siz Material
Waste Disposals Swim Pool / FE S
Wash Trays Indirect Wastes _ F re Fee
Washing Machines Drywell ain Drain Fee
Water Treat. Equip. Backflow Pre ven er Storm Drain Fee
Sinks Sury y Water Svs. Fee
Dental Units Gas Piping Fee
Drinking Fountains I Survey
Permit Fee
TOTAL TOTAL FEE
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial No. Lines Outlets Size
Rough _ Tested and Appr
Finish By _ --__