35133 (2) 1111 nERBYSqSRE DRIVE
Building Permit Confirmed ❑
Not Required LR-A
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
/. / 17Yq
.. Date---------------4F!.-_-1--.. ------------- 19/.47 Permit No--------3. -....J.�• ---------
The undersigned hereboe� p
a+i 1 he Ipector of the City of San Jose
for a permit to install plu li n e reverse side.
Eremp+ion from requ of Cali( rn. or n+rector's License is hereby claimed
by undersigned: ❑ statement filed
Undersigned attests that his State of jjcalif nie Conljjigdor's License #
is in full force and effect and properly a/i�ori/ is a 'o /�� .
San Jose ( ' Business License # /J
I certify that in the performance of +he work for w rich this pormi+ is issued I shall not employ
any person in any man or so as to viola+e the workmen's compensation laws of California.
OWNER
ADDRESS /��� 17F,�Bya �,�e �� Lot No.
USE OF BUILDING
SF�igned--. .- ..-. ' 22--'((�llam'
7111 DERBYSHIRE DRIVE LEE�poSIMLS
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