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• � J <br /> Application - Residential Building Permit <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E.HAZELTON AVENUE,STOCKTON,CA 95205 <br /> BUSINESS PHONE(209)468-3123 <br /> REQUEST FOR INSPECTION PHONE(209)468-3165(24 HOUR RECORDER) <br /> PERMIT NO. <br /> THIS SECTION IS TO BE FILLED OUT BY DEVELOPMENT SERVICES STAFF. <br /> SITE LOCATION INFORMATION Date: .2- 7 Z Technician: ap-el <br /> Job-Site Address: E t2APN: 177 B60 09 <br /> - <br /> Cross-Street: City: y„ ZIP: c� �j r <br /> Precise Location: b� / z, , <br /> Subd. History: <br /> Subdivision Name: a 7, 7 Map# BI/Lot# � p?� a1� �2 <br /> FACILITY INFORMATION <br /> Water Supply Existing On-She Well: New Onsite Well: Public: <br /> Sewage Disposal Existing Septic System: New Septic System: Public: <br /> Storm Drainage No Change: New Ory-She System: 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 APPLY FOR PERMITS <br /> REQUIRED TO BUILD A RESIDENCE <br /> Scope of Work: I F"h a JIB — 4 �L - d L4__JV l2on->\ A/ZW?, <br /> cC r Yb C, ()Ga V1/\ <br /> OWNER NAME//AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: l`� '✓ �Q,(/� �Al�j'�_ Name: <br /> Address: 760 O V 4 2 L , Address: <br /> City: /�/VlC 5 Ci4'v"� State: C Ctty State: <br /> ZIP: 3 Ph:(20) -s j ZIP: Ph:( ) <br /> CONTRACTOR INFORMATION Ph:( ) <br /> LIc. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph:( ) <br /> Llc. No: Company Name: <br /> Address: City: St: ZIP: <br /> WHO MAY APPLY? <br /> ONLY THE OWNER OF THE PROPERTY OR A LICENSED CONTRACTOR MAY TAKE OUT BUILDING PERMITS. <br /> Owner-Builder must submit the following with the application: <br /> • A property tax statement or s recorded deed <br /> • A completed and signed'Owner-Bullder 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 />