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�� � � � an'd � j Building Permit Confirmed ❑
Not Required ❑
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR MECHANICAL PERMIT
Date --- -.1 ...................._----..... 191 Permit No.------- ---> ..,3 ..... ------------
The undersigned hereby makes app' fI }o t o P mb' Ins c}or +ha City of San Jose
for a permit to install
the
mechanical or ise
Exemption from requirement for a iforn or nt or ense is hereby claimed
by undersigned: as owner ❑ statement filed ❑
Undersigned attests that his State of California Coniracfors License
is in full force and effect and properly authorises plicetioo
San Jose City Business License # 1% rte_
I certify that in the performance of the work or w ich Ihis p rmit is issued shall not employ
any person in any manner so as to viola}. the workmen's compensation laws of California.
1290-3
1154 acotlana lir. !H{4le1e3
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