83472 _---LLLI D e
t
Building Permit Confirmed ❑
Not Required
CITY OF SAN JOS BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
Z3 �� �3.y.� -
Date....--------....-----.. .'.'------...... - 19.....L. Permit No.....-- -.. ..--'---------'-----
Tho undersigned here makes a is io fb i9b' g I ci r of the Ci#y of San Jose
for a permit to install u i r pi s I' o e arse side.
Exemption from a r- o a or
for ontrecfor's License is hereby claimed
by undersigned: as owner ❑ statement filed ❑y3 .7 gd (y
Undersigned attests that his Stat of California Contractors License U
is in full force and effecf and prope
San Jose Cif y Business Licensee
I certify that in the performan of t e work for which this perm' is issued I shall not employ
any person in any manner so as to violate the workmen's compensation laws of California.
OWNER FLe71IV c_ J,
ADDRESS N Lot No.
USE OF BUILDING D� a /
28030 Aug. 69 Signed .�-.01 .�-.... ......
1111 Derbyshire Ace Plumbing Service
'FIXTURES FIXTURES MAIN DRAIN
Wafer Heaters Floor Drains Size Material
Wafer Closets Hoppers To I To Septic Tank
Bath Tubs Sand Traps RAIN WATER DRAINAGE
Showers Urinals Size Material
Lavatories Area Drains To Curb I 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 MachinesDrywell Main Drain Fee
Waferre
Tat. Equip. Backflow Preventer Storm Drain Fee
Sinks Survey Wafer Sys. Fee
Dental Units Gas Piping Fee
Drinking Fountains Survey
Permit Fee 2 d 0
TOTAL - TOTAL FEE �3, 0p
INSPECTOR'S REPORT HOUSE GAS PIPING
Partial No. Lines Outlets Size
Rough Tested and Approved
Finish By