3884 (2) 1118 Derbyshire Drive x
Tract No. Lot No.
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Dat TZ1'(')�. 21 . 19_!�—__— Permit No.
Application is hereb made for a permit to qj .I< clo
a 2_s+ory, ypeyn_'�S— Building_ Use Zone rr
Occupancy
to be occupied on as Parking Space
in accordance with Plans, Specificafio�lot--plan filed herewith. Fire Sprinkler.
Emer. Elect.
Estimated Value of Improvements, .$
I certify that in the performance�of the work for which this permit is issued I shall not employ any person
in any manner o as to violate'the workmen's compensation laws of California. r
Owner �@t� l Address li
By rV Address 1�cavr-+c—�
RECORD OF INSPECTION
Foundation _ Frame
Stucco Finish _
260-601N
1118 Derbyshire Drive
Exemption from requirement for State of California for Contractor's License is hereby claimed by applicant:
as owner ❑ statement filed ❑
Applicant attests that his State of California Contractor's License #
is in full force and effect and properly authorises this application.
San Jose City Business Lice�ng #
77 drn- aQ
280-601 N
: 711
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