83786 (2) 6191 Bolinger Road
Building Permit Confirmed ❑
Not Required [—
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR/PLUMBING and/or GAS PIPING PERMIT
Date....--------------..._/Q-/ s---- 19— / Permit No.------------R.37 F(.........—'----
The undersigned hereby makes application to the Plumbing Inspector of the City of San Jose
for a permit to install plumbing fixtures and/or pipes listed on the reverse side.
Exemption from requirement for State of California for Contractor's License is hereby claimed
by undersigned: as.owner ❑ - statement filed ❑
Undersigned attests that' his State of California Contractor's License # J
is in full force and effect and properly authorizes this,application.ry
San Jose City Business License # (,�✓_6r
1 certify that in the performance of the the wich this permit is issued I shall not employ
any person in any manner so as to v to the workmen's compensation laws of California.
OWNER U&L . 12E U n��L/ CN
ADDRESS6�9� °�/�GEy� /29' Lot No.
USE OF BUILDING CN�aze N
29030 Aug. 69
6191 Bolinger Road Central Serv. Co. If
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 I To Main Sewer
Kifchen Sinks Wafer 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 .00
TOTAL TOTAL FEE SD
INSPECTOR'S REPORT _ HOUSE GAS PIPING k elf
Parhal No. Lines Outlets Size '
Rough Tested and Approve
Finish By
a