9047 (2) 1089 Derbyshire
G` Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING/ and/or GAS PIPING PERMIT
Date.----------------------5 ..� ..... .. 19H. Permit No. ........ —'kI..-- ---
The undersigned here m m k s pli ';*'o + �wsgacfor of the City of San Jose
for a permit to install u as f�J+E reverse side.
Exemption from req remen} or Ste a of Cali ornia for Contractor's License is hereby claimed
by undersigned: as owner ❑ statement filed 02$ /257 C3`
Undersigned a}+esls 4hai his S aliformjjkk Conirac or' License #
is in full force and effect and pr a iho srsis �' !' ,L/ D/3 1H
San Jose City Business LicenY�
I certify that in the performance of the work �or which }his par i} is issued I shall not employ
any person in any manner so as to violate the workmen's compensation laws of California.
OWNER CL 5CAI S
ADDRESS UF9 DF/c3YSf//2E Di2 Lot No.
USE OF BUILDING �� S
280 30
� ,,
Signed 6�+l�,,"` U% ...d""":'!. ----------------------------
1089 Derbyshire n ace
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