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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 />INSPECTION REQUEST 24-HOUR RECORDER:(209)468-3165 <br />PERMIT NO:_ <br />THIS PORTIONOF THEAPPLICATIONMUSTBE COMPLETELYFILLEDOUTBY THEAPPLICANTIN ORDERTO APPLYFORPERMITS. <br />Scope of Work:1)erto ctrr I/JV Or It~Me:..,WA6 13(/{'l.Ar!:Pf)WJf./I .vAW H/ltl t./:'7re:A. <br />I Site Address:/00'/9 tiS C¥t?IV-8r:2L07{;120 <br />APN:.}o7 -037 -IS I Use of Structure:S~r.:D es C/ll-t?/v <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:7t:"tUCfU rE-Name:/).12.Tt:..C/1";V/CiAtV~'''IY?A"'" <br />Address:IOO,{CJ to Cf}-L§fV-Bt:;tLOTo e»,Address509 {;,S rOCK7{//{/S r; <br />City:t:!..sL~t-c?#State:CAL City:LOj);L State:CA <br />ZIP:q5~Ph:~tiJlf -Sd-7;2...ZIP:,)S',?-yt)Ph:~333'-6'190 <br />CONTRACTOR INFORMATION Ph:~607-/799 <br />Lic.No:~g'//7.s-Company Name:Xl?..>I'1tiJ(t-e /(tHe!.sozcecc: <br />Address:730!U Ut-1A JJ1l.I City:'£'0 P-,T se c,f ZIP:7~t5Z ~~ <br />DEPARTMENTS LISTED BELOW MUST GIVE APPROVAL PRI~RTO ISSUING DEMOLITION PERMIT , <br />Environmental Health Division Approval Signature:~~~8h\L Date Issued:J?I",",j1/ <br />"ySolidWasteDivisionApprovalSignature:Date Issued: <br />San Joaquin Valley Unified Air Pollution Control Date Issued: <br />District Approval Signature <br />WHO MAY APPLY <br />Only the owner of the property or licensed contractor may take out building permits •."'c'fl"~:".'.-!'. <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;•Current 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);•a completed "Authorization for Application"form if other than •a waiver form if the contractor is not subject to worker'stheownerapplied.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 />F.BlDGIHANOOl1TSlPERMIT APP-OEMOLITION.DOC File #82 (Revised 10.=)Page 1 of2