84507 854 Lily Ave.
Building Permit Confirmed ❑
Not Required ❑
` CITY OF SAN. JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING
and/or GAS PIPING PERMIT
Date----------------------------- , .... -
. .. --- ��
....--------
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 �ZC J
Undersigned attests that his State of California Contractor's License #
is in full force and effect and properly authorizes this applica;H Z
San Jose City Business License # 45;", -7
1 certify that in the performance of the work for which this permit is issued I shall nofr employ
any person in any manner so as to violate the workmen's compensation laws of California.
OWNER
ADDRESS Lot No.
USE OF BUILDING
280.30 Aug. 69 SI[3 ned......... ...... .. .....-..<� -.
854 Lily Ave. Lif et me
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
Drinking Fountains Survey
Permit Fee
TOTAL TOTAL FEE
INSPECTOR'S REP RT HOUSE GAS PIPING
No. L
-Partial, ines Outlets - Siz
Rough .„ Tested and Approved 4- -J0
Finish - By