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Application - Residential Building Permit SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 1-HAZELTON AVENUE,STOCKTON,CA 95205 BUSINESS PHONE(209)4683123 REQUEST FOR INSPECTION PHONE X209)468--3165(24 HOUR RECORDER) PERMIT NO. THIS SECTION IS TO BE FILLED OUT BY DEVELOPMENT SERVICES STAFF. SITE LOCATION INFORMATION Date: Technician: Job-Site Address: �f C " APN:// 2 -Q -0Z le Cross-Street: City: ZIP: X520 j Precise Location: O y d? �� I �p tZ, ; /!�+ Subd. History: Subdivision Name: Map# BI/Lot# FACILITY INFORMATION;. Water Supply Existing Onsite Well: New Onsite Well: Public: Sewage Disposal Existing Septic System: New Septic System: Public: Storm Drainage No Change: New On-She System: Public: Driveway/Access Existing Driveway: New With Curb-Gutter: New Without Curb-Gutter: THIS PORTION OF THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR PERMITS REQUIRED TO BUILD A RESIDENCE- Scope of Work: OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: Name: Address: Address: City: State: City State: ZIP: Ph:( ) ZIP: Ph:( ) CONTRACTOR INFORMATION Ph:( ) Llc. No: Company Name: Address: City: St: ZIP: DESIGNER INFORMATION Ph:( ) LIc. No: Company Name: Address: City: St: ZIP: WHO MAY APPLY 4 ONLY THE OWNER OF THE PROPERTY OR A LICENSED CONTRACTOR MAY TAKE OUT BUILDING PERUM Owner-Builder must submit the following with the application: • A property tax statement or a recorded deed • A completed and signed'Owner-Builder Verification'form • A completed'Authorization for Application'form If other than the owner applies. Contractor must submit the following with the application: • Current license numbers and a worker's compensation insurance certification (this is not necessary if this information is already on file with the Department) • A waiver form if the contractor is not subject to worker's compensation laws • A completed'Authorized to Sign'form H other than the contractor applies(this is not necessary if this Information is already on file with the Departrnent).