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5 5 <br /> Application Commercial Building Kermit <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E HAZELTON AVENUE,STOCKTCK CA.9x205 <br /> BUStINESS PHONE(209)4683123 <br /> REQUEST FOR INSPECTION PHONE(209)4683165(24 HOUR RECORDED <br /> PERMIT NO. �200�0 <br /> THIS SECTION IS TO BE FILLED OUT BY DEVELOPMENT SI+RVICES STAFF.: <br /> SITE LOCATION INFORMATION Date: pZ Z Technician: <br /> Job-Site Address: �j /Ef�z �C v APN: <br /> Cross-Street: Z�C �� c� / City: /� c) ZIIP: <br /> Precise Locatio.i: r �! �,�� ? Ci 9 el7/ O c a!7 <br /> b D� SGc� Subd. History: <br /> Subdivision Name: Map # BI/Lot# <br /> FACILITY INFORMATION <br /> Water Supply Existing On-Site Well: New On-Site Well: Public: <br /> Sewage Disposal Existing Septic System: New Septic System: f/ Public: <br /> Storm Drainage No Change: New Onsite System: <br /> 15 Public: <br /> Driveway/Access Existing Driveway: New With Curb-Gutter: New Without Curb-Gutter: <br /> THIS PORTION OF THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT,IN ORDER tO AP1�LY .0 p NMI <br /> REQUIRED TO BUILD A COMMERCIAL STRUCTURE <br /> Scope of Work: <br /> Business Name (DBA): Bus. Lic. No.: <br /> OWNER NAME AND ADDRESS APPLICANT !AME AND ADDRESS <br /> Name: ` / r�r Yv S Name: &,o e <br /> Address: v r,c r Address: <br /> City: State: City State: <br /> ZIP: Ph:i,)69 �c�I y3 ZIP: Ph:( ) <br /> CONTRACTOR:INFORMATION Ph:( ) <br /> Llc. No: ll Company Name: rfJv �� / S <br /> Address: U_ (?vK t � ���`jdyl City: (r/,Q,-`j�,�< St: ZIP: J�6 <br /> ..... ........... _ _._....... _._ _ .._ .._................__...... <br /> _.._......... _..__. .._....... _. _ . ... .. _.__. .._. <br /> DESfGNE1 1NORMATION Ph:( ) <br /> Lic. No: Company Name: <br /> Address: � City:��{` St: ZIP: <br /> WHO MAY APPLY? <br /> ONLY THE dWNEii daF YHtr PF OPEHTY OCt A LICENSEb CZINY1EtAC 1 Osa W1X 7AK 'btJh.80 LDING FtAl11'3. <br /> Owner-Builder must submit the following with the application: <br /> • A property tax statement or a recorded deed <br /> • A completed and signed'Owner-Builder Verification'form <br /> • A completed'Authorization for Application'form If other than the owner applies. <br /> Contractor must submit the following with the application: <br /> • Current license numbers and a worker's compensation insurance certification (this is not necessary If this Information is already <br /> on file with the Department) <br /> • A waiver form If the contractor Is not subject to worker's compensation laws <br /> • A completed'Authorized to Sign'form if other than the contractor applies (this Is not necessary If this information Is already on <br /> file with the Department). <br /> A <br />