20117 (2) 6912 SHADY GROVE
Building Permit Confirm
I Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
c 7//'
Date............... .- 3 �� � - - 19_ZlriPermit No..�.�lG./..
The undersigned hereby make application to the Plumbing Inspector of he City of San Jose
for a permit to install plumbin / s verse side.
Exemption from requiremen a r C n or's License is hereby,claimed
by undersigned: as o ner ❑ statement filed ❑�O�/7�r
Undersigned attests that his State of California Contractor's License #
is in full force and effect and properly authorizes this�ep lyvation�
San Jose City Business License #
I certify that in the performance of the work for which this permit is issue I shall not employ
any person in any ner so as to violate the woOm�n's compensation laws of California.
OWNER
ADDRESS c f�� Lot No.
USE OF BUILDING cg=25:2f!� /
280-30(9-73) Signed_l�.. ..V.....:LC%/� .._-----........
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6212 SHAKY GROVE AP OS
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