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� �UV," APPLICATION - DEMOLITION PERMIT <br /> r' SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE. (209) 468-3121 <br /> c4i ��;p INSPECTION REQUEST 24-HOUR RECORDER: (209)468-3165 <br /> as <br /> PERMIT NO: <br /> This PORTtON OF THE APPLICATIOWMUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR"PERMITS. <br /> Scope of Work: Site <br /> i <br /> Site Address: 7 <br /> APN: (��- 20- 0 7 Use of Structure: <br /> OWNER NAME:AND ADDRESS `dPPLICANT NAME AND ADDRESS <br /> Name: 1wG:+ ,o Name: <br /> Address: 7 � ,Q� Address: a } 2 <br /> City: � � e= State: � City: �� State: <br /> ZIP: r3 Ph:( } ZIP: n T 7 Ph:Mq Z�V—7 )Cj N <br /> CONTRACTOR INFQRI11lATfOIV +4 Ph:( <br /> Lic. No: '���`" Company Name: <br /> Address: �Q F City: St• ZIP:�j 79 <br /> :3 a..:f t ay €^,�: '8tc. - tFk%ie+ '�I s' i.O .rc v?rR>" <br /> DEPARTMENTS LSTE BELW lull T,GIY PP,ROY-APRI €R70 ISS ,ING;DEMO,L[TIONPE�RMIt r <br /> Environmental Health Division Approval Si atur : Date Issued: <br /> Solid Waste Division Approval Signature: Date Issued: <br /> San Joaquin Valley Unified Air Pollution Con of Date Issued: <br /> District Approval Signature <br /> � '. � x �'���� ��� ��,�?'� ���`��-,��. � '� ��,:�"►Illk�(?aM�►Y,�Af�iP,L1,' _ �; ��i�' , .�� ��°�' ���"��3�� ' <br /> X , tOnlf00i~��ofthe "r ',,rkarllsicl�Gontra�cima .,fk� "utbutltlien, e`mitsr <br /> C 'Owner/Builder must submit the following with the application: Conkractor must submit the following with the application: <br /> • A property tax statement or a recorded deed; Currenk 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 . a waiver form if the contractor is not subject to worker's <br /> I the owner applied. l! 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.-BLOO)HA.NOOEITSWERMIT APP-DEMOLITIONMOC File#82(Revised 7620-02) Page 1 Of 2 <br />