21612 1169 9TAP FORD ��1�E PHONE: 277-4581
fVl Building Permit Confirmed ❑
No+ Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
PPLICATIOrr--N FOR MECHANICAL PERMIT
Date.... .. ......................d Y . ...... `1�9'm�..e1. Porrni+ No.. 002-4(0 1�..... ........
The undersigned hereby,mato®�/.ppl�ali6n'}o�, e,Pl ngc}or of the City of Sen Jose
for a permit to install the mechanicalywork listed on the reverse side.
Exemption from requirement for Stateo California for Contractor's License.is hereby claimed
by undersigned: as owner stat�me �iled� (ljf'
Undersigned attests that his State of allfornia Contra cto'r's/Lmame #
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 no+ m la
any person in any manner-so as to viola}e the workman's compens}�},ifon le(�s of Celif�No.
ornie. (J _
OWNER �c��lvt � - nn�(rrfCI�IP / 6CfADDRESSy q S �1 t� r� I •
y� �`` II 2,'
USE OF BUILDING R RS f P P
Signed-..... --
280-404N
1109 STAFFORDt?DRIVE OWNER
� \ .
-
} } _ { } } ( Lu
\�
} } aaz ` -
/ , §
» . G ~) \ .
/ } ®
-
�f
§ I02 ! } � - MO