12818 921 Ferngrove Dr..
Building Permit Confirmed ❑
17 Not Required
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
.. Date--------------------------r-.- --.--- ... 19.7).. Permit No---------------1...zl:�Ipl ---------
The undersigned hereby makes application to the PI bing Inspector of the City of San Jose
fora permit to in a I pl an p'I rn s} don the reverse side.
Exemption fr of 54 of al rn or Contractor's License is hereby claimed
by undersigned: as owner7l�� statement filed ❑ pl 2 j 7�
Undersigned attests that his State oyye -ia r } r//Ljle a ,<O
is in full force and effect and properly h ri s } s a o � t/
San Jose City Business License # 77 /
I certify that in the performance of the work for which this permit is issued I shall not employ
any person in any manner so as to yiolafe the workmen's compensation laws of California.
OWNER /,-7 T 12•
ADDRESS `1 I qF��tiG2o v� DR Lot No.
USE OF BUILDING
280-30(9-73) Signed
921 fldhhgrove Bir. C Ave.
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