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APPLICATION ® DEMOLITION PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> { 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> � 1a INSPECTION REQUEST 24-HOUR RECORDER: (209) 468-3165 <br /> ltx©R <br /> PERMIT NO: <br /> THIS PORTION OF THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR PERMITS. <br /> Scope of Work: j ��:�z�����Jc�v J���✓� �ld�t ,c <br /> PtAc-T1GG Auly) - vel -r Site Address: <br /> APN: ®� - d�0- J Use of Structure: <br /> OWNER NAME AND ADDRESS , APPLICANT NAME AND ADDRESS <br /> J ' / <br /> Name:7`�/ `v� � Name: <br /> Address:` Lj6 Address: <br /> City. State: �� City: /� State: <br /> ZIP: �Q Ph:( �� X515- �7�1�i ZIP ��'�� Ph S�l✓� /7c�� <br /> CONTRACTOR INFORMATION Ph:( ) <br /> Lie. No: Company Name: •�/� j� �T�� FMP- (,7,=-7` — <br /> Address: City St: ZIP: j <br /> DEPARTMENTS LISTED BELOW`MUST GIVE`APPROVAL PRIOR TO ISSUING DEMOLITION PERMIT <br /> Environmental Health Division Approval Signature: _ Date Issued: 1 <br /> Solid Waste Division Approval Signature: Date Issued: 1/5116 <br /> San Joaquin Valley Unified Air Pollution Control Date Issued: <br /> District Approval Signature <br /> WHO MAY_APPLY <br /> Oni the®weer of the r446'.6r liceiiseld contractor irl Rile qt l� ilding._ ermits, <br /> Owner/Builder must submit the following with the application: Contractor must submit the following with the application: <br /> • A property tax statement or a recorded deed; 0Current license numbers and a worker's compensation <br /> • a completed and signed"Owner/Builder Verification"form; and insurance certificate(this is not necessary if this information <br /> is already on file with this department); <br /> • a completed"Authorization for Application"form if other than 0 a waiver form if the contractor is not subject to worker's <br /> the owner applied. compensation laws;and ^/ <br /> • a completed"Authorized to Sign form if other than the <br /> contractor applies(this is not necessary if this information is <br /> already on file with this department). <br /> qr0 <br /> .� <br /> ..aHyl/i G'jZ,L:..(G� Cc.�L`•�'v2.0 C 7L[G..�;..�,� <br /> F:BLDO/HANDOUTS/PERMIT APP-DEMOLITION.DOC File#82(Revised 10.20.02) Page 1 of 2 Cz f � 5 <br />