81784 8084 Park Villa Circle
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR GAS PERMIT
Da+ Lu ..4 LM-------------- 19--------.. Permit No......U.../ _0.... ..
The undersigned hereby, ?.ales??application
ttoA+�ej��m�i'ng Inspector of the City
of San Jose for a pertitito1'A0 •said?a plianees an or gas pipes as listed on the
reverse side hereof, and agrees to install said appliances and/or pipes in accordance
with the provisions of Article VIII, Chapter d4aof the Sanp Jose�Municipal Code, and
other laws applicable thereto.
certify that in the performance of the WOrrk for'wKich this permii/is issued
shall not employ any person in any manner so as to violate the workmen's com-
pensaiion laws of California.
OWNER
..%./... .Gr _.........._...—._-...- -----------_..... ------------ -
.... LOT NO.aO_.._....ADDRESS.( U ---1 .� 5
USE OF BUILDINGRESIDENCE... ..._............ ---------------
280-20 1 Rev. Apr. b'71 SignedNiERCUR.Y_S.HLEi..M1:TAl,�✓�- . . ...------- -- --.. -
AnAla Dnrk Vi 11 a Ci rel a `% o% y'�[eYctlry S�1
p
Type of Appliance No. Remarks (CheckNew Replace
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Automatic Controls
Flue and/or Vent j
Hood and/or Duct
Clothes Dryer
Permit Fee ' ob
TOTAL -
yo
FEE v`r
Inspected and Approved —)-3 _7 L—By
HOUSE GAS PIPING
Number of Outletsi Size of Main
FEE
Tested and Approved By