20557 (2) 1111 DERBYSHIRE DR
Building Permit Confirmed ❑^ '
Not Required L1—
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or G S PIPING PERMIT
Date.. i _. ...... .._....-------.. 19/J. ./!. Permit N
The ndersigne hereby makes applica,ion to e�Plum Inspector of the City of Sen Jose
for a permit to ' fa f' r d/ pi tho reyerse side.
Exemption f of i / a rni f or
License is hereby claimed
by undersigned: es owner ❑ statement filed
Undersigned affests that his State f California Contractor's Li/c/ansa
is in full forco and affect and proper) a f s hi et' y�r//
Sen Jose City Business License # _(�,r/ fyy/rf/"y"/
1 certify that in the performance of the work for which this perms# is issuod I shall not employ
any person in any maRM o as to violate the workmen's compensation laws of California.
LI
OWNER1
ADDRESS _//�J / l2CLLv(�L Lot No.
USE OF BUILDING-
280-30
UILDING _280-30(9-73) - Signed------ .-- --._L/ .. -
1111 DERBYSHIRE DRD `
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