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BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �NIV�Imo' 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> �P <br /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> 9<tFORa <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS:'" <br /> ScopeofWork: +: euV� lv � nc view 2 'rU�r Vit - EU P �`c��v <br /> Project Address: 30 ci-&­r 2-f RA <br /> Project Valuation: ( 25,000 pG Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: (" Name: V rte: (fir t c <br /> Address: �U ZL} [ `j Address: ,')0 ' C' { <br /> City: � v��� State: �_ City: C 4�k-p„ State: Cji <br /> ZIP: Cd LO Ph#(�_ I ) >I'�� C l t. ZIP: " j G�e Ph#(?tT 5 <br /> CONTRACTOR INFORMATION Ph#(!C(-J) g�t � - E ( 'J-- <br /> Lic. No: c Company Name: - <br /> Address: ,1 ' l(; ( ,..a c1 f , City: St:(14A ZIP: (c" >`> <br /> DESIGNER INFORMATION Ph#(J7?) 9¢j? — zl3L <br /> Lic. No: aj_o0067 Ij Company Name: C 5 .PX/4 FT/p,/ <br /> Address: 4-ol 5, FL DOK-A 0 57 Z-T City: St GQ— Zip: 95-203 <br /> LENDING AGENCY Ph#(GAu ) jcj C, 1 ( <br /> Company Name: Z_.1> <br /> Address: C: c#l_' jY ctQ l ._t City: L� < "r t'l; St: (p ZIP: <br /> Permit will be issued to an "Owner-Builder' Yes ❑ No ® OFFICIAL USE ONLY <br /> If yes, a completed Owner-Builder Verification Form must Identification Number: <br /> be signed and submitted along with copy of the owner's <br /> identification prior to issuance of the building permit. <br /> DECLARATIQN BY CONSTRUCTION PERMIT APPLICANT <br /> By my signature below, I certify to one of the following: <br /> I am ❑ a California licensed contractor orathe property owner or❑ authorized to act on the property owner's <br /> behalf(requires written approval and Owner/Builder Verification Form signed and submitted). <br /> I have read this construction permit application and the information I have provided is correct. <br /> I agree to comply with all applicable county ordinances and state laws relating to building construction, I authorize <br /> representatives of this city or county to enter the above-identified property for inspection purposes. <br /> Applicant's Signature Date <br /> For your convenience checklists detailing any additional submittal requirements for various building permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:Wpplication Forms&HandoutslHANDOUTS\Building Permit Applicalion.docPage 1 of 2 <br /> (Revised(07-08-10) <br /> I <br />