30669 (2) 1118 DERBYSHIRE ➢R
Building Permit Confirmed
Not Required ❑
CITY OF SAN JOSE BUILDING,DEPARTMENT
APPLICATION FOR PLUMBING and/or,GAS PIPING PERMIT
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Date., .../ver 1977- Permit No. �.Q.G-e'----.L--------------
.. . ... _
The undersigned hereby makes application to the Plumbing Inspector of the City of San Jose
for a permit to install' plumbing fixtures and/or pipes listed on the reverse side.
Exemption from requirement for State of California for Contractor's License is hereby claimed
by undersigned: as owner Z__ statement filed ❑
Undersigned attests that his State of California Contiactor'sLicense #'
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 not employ
any person in any manner so as to violate the workmen's compensation laws of California.
OWNER y v yfl t o a4 zazj,6f nn/J 1 �✓
ADDRESS /0'? � � a(�L • Lot No.
USE OF BUILDING Po-a
Signed 2&'o,-.St/�
P..�. -...
280-401n
1118 DERBYSHIRE DR OWNER
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