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F <br /> °P 0(71 <br /> APPLICATION - DEMOLITION PERMIT <br /> ).•'�ct'cOG <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> c4��koR��P INSPECTION REQUEST 24-HOUR RECORDER: (209) 468-3165 <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 Xl6 ' l y{�s <br /> Site Address:l(?gd Q F <br /> Use of Structure: �i��h <br /> . <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: I 7 017 <br /> Address: 0J Address: S' Q ���/ <br /> City: e State: p� d <br /> �/l City: State: <br /> ZIP: J3 Ph:( ) ZIP: /� f <br /> V Ph:00 hL J /(3 f 'i <br /> CONTRACTOR INFORMATION <br /> Ph:a) j <br /> Lic. No: 7` , t Company Name: I�� <br /> Address: (� �y City: <br /> St: /� ZIP: <br /> DEPARTMENTS LISTED BELOW MUST GIVE AP ROVAL PRIOR ISSUING DEMOLITION PERMIT <br /> Environmental Health Division Approval Signature: Z <br /> Date Issued: <br /> Solid Waste Division Approval Signature: <br /> San Joaquin Valley Unified Air Pollution Control Date Issued: <br /> District Approval Signature Date Issued: ' a D( <br /> WHO MAY APPLY <br /> Only the owner of the property or licensed contractor may take out building permits. <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; 0 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 /> • a completed"Authorization for Application"form if other than is already on file with this department); <br /> the owner applied. a waiver form if the contractor is not subject to worker's <br /> 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:BLDG/HANDOUTS/PERMITAPP-DEMOLITION.DOC File N82(R-ised 10-20-02) Page 1 of 2 <br />