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Olfi;?tzuu 13 53 FAX 'L0341j831b3 si tumn utv vuIfvvz <br /> SAN JOAQUIN COUNTY <br /> CWNUWY DEYELOPIAM DEPARMENT <br /> ie�a�. raa.roe ,wr.a�acKr�,rro�s� <br /> :�: resat 2W409-3121 FAX 2W4ft j= <br /> OWNER/BUII1DER'VERMCA.TION]FORINT <br /> AMORIZATION FOR APPLICATION FOR PERMTT(S) BY OTHER THAN <br /> THE PROPER'T'Y OWNER OR A LICENSED CONTRACTOR <br /> 1, as the owner of the property, understand or have been informed that the application for a Building, dumbing, <br /> and/or Electrical Permit must be signed by the owner of the property, his duly authorized agent or a licenaed <br /> contractor'. <br /> I atu also aware tbA I may designme a third party, such as a tenant or person in my employ, to sign the application for <br /> r a permit on my behalf I understand that the person's only responsibility or function is to acquire a permit on my <br /> t behalf. i <br /> I am aware that the responsibility for the construction and compliance to codes and ordinances is entirely mine and I <br /> agree to accept the same. <br /> Therefore; as the owner of <br /> (Addma of time site were work will be perfmumd) <br /> I do hereby authorizeFMn d M , D PE <br /> (Nam of parson au&or&ed to obtain permit) <br /> to obtain a <br /> (7�jm of permit and deamiptim of work) <br /> a my name by affixing my name followed by his or her signature on the application. <br /> )wnees Signator <br /> Iwner's Address/City e= 2- FrC41q-5-Z51 <br /> )wner's Telephone Number 6310� 9 K5-9!1 o t- aj teoc -� <br /> 11 FML 0UT BOTH SIDES OF THIS FORM IF BOX IS MARKED <br />