21804 66ES°TATE5_Dftm PHONE: 277-4581
Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR MECHANICAL (PERMIT
Date... ... _.---I�/ � ?.I...._..._._. 197y. Permit No.......:Zl. d.C1.......... .....
The undersigned hereby makes application to the Plumbing Inspector of the City of San Jose
for a permit to install the mechanical work 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 # niJy —
is in full force and effect and properly authorizes this application.
San Jose City Business License #
I certify that in the performance of the work for which this permit is issued I shall not employ
any parson in any/fan/ner so as to violahe the workmen's compensation laws of California.
OWNER�7ol�J
ADDRESS Slv a �.�/ '� Lot No.
USE OF BUILDING Q
Signed---- - -- -- ---- --------- ----- ---- -----------_......._...---
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862 ESTATES DRIVE FIREPLACE DISTRIBUTORS
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