28873 (2) 1128 DERBYSHIRE DR
^ Building Permit Confirmed A—
l/ Not Required ❑
CITY OF SAN JOSE 1/ BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS
/7PIPING 7PERMIT
Dale-----------------------------/P .-l .. 19,77Permit No.---_Q-`...2f...Q...L.--...........
The undersigned here makos applicafi t he Plumbing Insp r of the City of San Jose
for a permit }o install mb' g re a d�fisf r arse side.
Exemption from re ui ate a is C r is License is hereby claimed
by undersigned: s,owner s}a}ement filed 'g}
Undersigned attests that
h' S}a}e of California Contractor's License # — Z V
is in full force and effect and p erl a ho ' as is 1* t,
San Jose City Business Lice a
I certify }hat i per(oi n fha w is fl pe ' s ed I shall not employ
any person in mann so as }o violafe }heyorkmon's compensation laws of California.
OWN
ADDRESSZ2 p, Lot No.
/ r
USE OF BUILDING
Signed_..... .// .. ........
0DNS/.
280�4401n
1128 DERBYSHIRE DR DEL MAR CONST
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