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D BUILDING PERMIT APPLICATION <br /> mSAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E.HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY PILED:OUT BY THEAA. PLICANT7N IMI R TO APPLY FOR <br /> BUILPWQ PE;RMIT$a i <br /> Scope of Work: <br /> Project Address: /�2 f�®� - <br /> Project Valuation ®o Contact E-mail: rTo s NCT <br /> dVifNER NAME AND`ADDRESS APPLICANT NAME,AND ADDRESS <br /> Name: G f G Name: V p . <br /> Address: ftp Z Gc yyeI-ro c.. /W Address: �� yyl de: <br /> State:L,Vl- City: s��p� State: 4��& <br /> ZIP: Ph#( ) S3/ - �Jr'J1 ZIP: 2 r Ph# ) -7�Tr <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: Ula,, <br /> Address: , f1 Aye- City: :cGa L — St: ZIP: <br /> DESIGNER INFORryfAT10N Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> LEN�ING 71GE{JOY Ph#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes❑ No Q b (IOlAL USP,O I Y r <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 /> DECLARATION BY OONSTRUCTION REP_ TAPPLICANT <br /> By my signature below, I certify to one of the following: <br /> I am�a California licensed contractor or❑the property owner or E]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 alt applicable county ordinances and state laws relating to building construction, I authorize <br /> representatives of this city <br /> y000rr cc000uun�t-y' to enter the above-identified property for inspection purposes.. <br /> Applicant's SignaturE,s 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 /> FAApplication Farms&HandoutslHANDOUTS1Building Penni(Applica(ion.docPage 1 of 2 <br /> (Revised(07-08-10) - <br />