37797 1110c OtA
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CITY OF SAN JOSE , A�t BUILDING DEPARTMENT
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APPLICATION FOR BUILDING PERMIT
Date... M-4w/a Pe m'f No-7-7-7 r
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Application is hereby made for a permit toe��P
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a........../----story, TP 5- ...... ------- --------------- Building
to be occupied only as -------- --------------------
in accordance with Plans, Specifications and P:;Jg; f4illWillfl
Estimated Value of improvements, $..1/..'-50.....0'1.......--..
It is hereby agreed that the requirements of the San Jose Building and Zoning Ordinances and all other
laws applicable to the construction, location, and use of buildings within the City of San Jose, will be
complied with.
I certify that in the performance of the work for which this permit is issued I shall not employ any per.
son in any manner so as to violate the workmen's compensation laws of California.
Owne ---Address -rjX
By ....Address
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.........w....Aciclress,f,!
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................ ------------ .
Contract r, Agent
Form 280-1
RECORD OF INSPECTION
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