73180 942 S&ptdmb&e ^/ 1
/ Building Permit Confirmed ❑
Not Required D.
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS
—7PIPING PERMIT
Date..--F---- -------------------------- 19-�Permi{ No------------7-�—r-J-----------
The und.rsignad he by makes application to the Plumbing Inspector of the City of San Jose
for a permit to inst p n {' g n ip lis the reverse side.
Exemption from i a 6f a or onfra.for's License is hereby claimed
by undersigned: as owner ❑ statement filed ❑
Undersigned d attests that his State of Californi cto.=s y� _(
is in full force and effect and properly authorizes ba icati
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 manner so as to Acl�ate the workmen's compensation laws of California.
OWNER cC� X tl �SObn�
ADDRESS
USE OF BUILDING
FORM 2800 10W1 3/67 / Signed------.... �'
942 September '�����"A'nCrbny Pot
FIXTURES FIXTURES MAIN DRAIN
Water Heaters / Floor Drains Size Material
Water Closets Hoppers -fo--
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 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 z
TOTAL TOTAL FEE j C �-
INSPECTOR'S EPORT HOUSE GAS PIPING
Partial " J��Aa No. Lines Outlets Size
Rough Tested and Approved
Finish By