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"'"•.� SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E. HAZELTON AVE., STOCKTON, CA 86206-6232 <br />PHONE: 2091188.3121 FAX: 209/466-3163 <br />OWNER/BUILDER VERIFICATION FORM <br />AUTHORIZATION FOR APPLICATION FOR PERMITS) BY OTHER THAN <br />THE PROPERTY OWNER OR A LICENSED CONTRACTOR <br />i <br />I, as the owner of the property, understand or have been informed that the application for a Building, Plumbing, <br />and/or Electrical Permit must be signed by the owner of the property, his duly authorized agent or a licensed <br />contractor. <br />I am also aware that I may designate a third party, such as a tenant or person in my employ, to sign the application for <br />a permit on my behalf I understand that the person's only responsibility or function is to acquire a permit on my <br />behalf. <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 />I do hereby authorize _ <br />(Address of the site where work will be performed) <br />(Name of person authorized to obtain permit) <br />to obtain a <br />(Type of permit and description of work) <br />in my name by affixing my name followed by his or her signature on the application. <br />Owner's Signature <br />Owner's Address/City <br />wner's Telephone Number <br />; <br />FILL OUT BOTH SIDES OF THIS FORM IF BOX IS MARKED <br />Comm. Develop. 29 (04105) <br />