76302 1141 Hollyhead Lane
Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING
77 PERMIT
Date--`-- .. -.--- - - /--_......_--. 19�-KPerrnif No.... - Yd----.---------
Tho undersigned hereby makes application 10 4he Plumbing Inspector o4 the City o4 San Jose
for a permit fo install in re r pi as IiS}e o reverse side.
Exemption from re i r o actor's License is hereby claimed
by undersigned: as owner ❑ statement filed ❑
Undersigned attests }hat his St fa of California Contractor's License # �.�71�7 d
is in full force end effect and pri
horxaL
San Jose City Business Licens #
I certify that in the performance of the wo4 for which this permit�is issued I shall not employ
any person in any manner so as to violate the workmen's compensation laws of California.
OWNER A- /lam !�
ADDRESS
USE OF BUILDING
d
FORM 280-30 10M I/saSigne ^^-------------------------�-��. Ace
*C-. /_ /
1141 Hollvhead Lane
FIXTURES FIXTURES MAIN DRAIN
Wafer 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 Size Material
Waste Disposals Swim Pool FEES
Wash Trays Indirect Wastes Fixture Fee 7 ,, �y-(j
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 FEE
INSPECTOR'S REPORT HOUSE GAS PIPING
rartial No. Lines Outlets Size
tough Tested and Approved
'inish -�;/ // By
Lct,�c- 7—//— 6 f, .1%vs woF#-7 6 3 a-4—