67744 (2) 7642 iiollanderry
9 Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATIO//N FOR PLUMBING and/or GAS PI/PING PERMIT
Date �/l/ fo 77 y y
-------- ---------------......-- 19.(a./-. Permit No.-.....-----------------------------------....
The undersigned heremakes application to the Plliu76��' Inspector of the City of San Jose
for a perm'} }o install 0 'rM1a s n the reverse side.
Exemption from re e e r a lit i Contractor's License is hereby claimed
by undersigned: as owner ❑ sfafe enf filed �' _ 3�
Undersigned attests that his Sta of lifer o it c r' ��cceense
is in full force and effect and prop r oriz
San Jose City Business License �e -
I certify that in the performance of the w rk for which this permit is issued I shall not employ
any person in any anner so as to violat }h work ens compensation laws of California.
OWNER
ADDRESS
USE OF BUILDING
FORM 290.301FEV. 3I64i lOM Signed .. .. .. ---- ----
76Lk2 HD:klanderry Lr Servisrit
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 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
DrinkingFountains Survey
Permit Fee
TOTAL TOTAL FEE ,
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial No. Lines Outlets Size
Rough Tested and Approved
Finish S , LIlL 7 4r vY By
. , r