81784 8086 Park Villa Circle
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR GAS PERMIT
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Date 4�� -Akwa...................... I9.p/... Permit No.------..1/../...L..(1...../....
The undersigned hereby markgs,applic�i n to the Plumbing Inspector of the City
of San Jose for a permit�% ;s�all�sid�ap�l�n �or�c as pipes as listed on the
reverse side hereof, 'ind agrees to insta�saidoapPliance�nd/or pipes in accordance
with the provisions of Artiel�e VIII, Chapter 4, of the San Jose Municipal Code, and
other laws applicable thereto.
I certify that in the performance of the k for whichP094 permit�isgr'%ssue
/word I
shall not employ any person in any manner so as to violate the workmen's com-
pensation laws of California.
OWNER .. --��:..... ................. ..................._ -------------/ --------- ..
ADDRESS.. vf-p � ._ LG .. _. ..... ......_.... LOT NO.I- ..
USE OF BUILDING RESIDENCE ..
280-20 (Rev. Apr. 69) Signed Pd.E.R�URY_SHEET.-ldETA `--% - ------
8086 Park Villa Circle er S
4-
Type of Appliance No. Remarks (Check V)
New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnaces / W
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
Automatic Controls
Flue and/or Vent cr7
Hood and/or Duct
Clothes Dr er
Permit Fee
TOTAL —�
FEE
Inspected and Approved?- J3 -72-ByAe-P� rt/
HOUSE GAS PIPING
Number of Outlets Size of Main
FEE
Tested and Approved 'By