80233 (2) 1040 Colony Hills
Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPPING PERMIT
Date ' ---------y.:..3-------------. 19-01'ermi# No.----7.....C..D... _.-73:......:
The undersigned her y ekes i to Plpacior of the City of Sen Jose
for a permit to
ins#all hu
i � � r pe a n e reverse side. '
Exemption from require a or S# a of ifo in or tractor's License is hereby claimed
by undersigned: as owner ❑ 'statement filed_[cyj/�p.tel/
Undersigned attests that his Sia#e�. f Cal' ornia Contractor's License
is in full force and effect and properl/ al�th s } ' � . .
Sen Jose City Business License T�41 - -- ,
I certify #ha+ in the performance ffie or for which this permit is isdied I shall not employ
any person in any manner o as to-violate i orkmen's compensation laws of California.
OWNER AN O
ADDRESS OleA _' /6j
USE OF BUILDING S"! J
.Signed ----- - - --- ---- -- - ----- /... . . `.
zeo-eo ro-ae
1040 Colonv Hills Delta talolo"
FIXTURES FIXTURES MAIN DRAIN
Water Heaters Floor Drains Size Material
Water 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 Size I 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 FEEf,
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial No. Lines Outlets Size
Rough Tested and Approvedi,
Finish By