45356 (2) , 1107 Derbyshire
CITY OF SAN JOSE BUILDING DEPARTMENT .
APPLICATION FOR BUILDING PERMIT
TractNo.......................Lot No._....._..........
Date----------------------01.j�7t. f.......... 19..6 --- Permit NoJ-11 .....----------
Application is hereby m de for a permit to '. ... s,d
a---------�------story. Type.... ... --- --- - ----....................--/----Building
Use Zone-....R5--..-t......
rJ ,Q i ancy----- ------------
to be occupied only as .l tlJ.`1A`�. ---.���f�' W�r�Cifig Space.--._?................
in accordance with Plans, Specifications and Plot-plan filed herewith.
Estimated Value of Improvements,$. v v.:.........................
It is hereby agreed that the requirements of the Sen 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 person in
any mann/err so as to violate the workmen's compensation laws of California.
Owner-!.!------cz, .............................Address............................................--------------- -
Contractor
By Agent ..... t '- .-..Address...l�ULu�y5 .�/,u-...1/J�
1107 Derb hire H.C. Jackson
RECORD OF INSPECTION
Foundafion............................................................Frame.....................................................................
Sfucco.................. o.� v Q
........................................... ...........
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Form 280.1—IOM-12-63