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oR4ulrr BlJ1LVIltl �PERMIT /`1Pf LIIyH 1 ®N <br /> SAN JOAQUIN COUNTYNITY DEVELOPMENT DEPARTMENT <br /> w`• ', 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> c'YraaN INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BYTHEAPPLICANT IN ORDER?O APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: <br /> Project Address: <br /> Project Valuation: —aso Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: �j` �k/Y �ln ! _ Name: 911, t (e � <br /> Address: _ (� (yM /� y /3 (v Address: .a q f'i, <br /> �: C �( / <br /> Ci State: c�- City:L z�ll State: <br /> C� <br /> ZIP: i d I-0- Ph#(ac )3co - 3°i o ZIP: 5 d- Y� Ph#( ) <br /> CONTRACTOR INFORMATION Ph#(-U1) q-1 GU�� <br /> Lic. No: Company Name: <br /> Address:, City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> L(c, No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address: City: St: 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 owners <br /> identification prior to issuance of the building permit. <br /> DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br /> [behalf <br /> y my signature below, I certify to one of the following: <br /> m�alifornla licensed contractor or El the property owner or❑authorized to act on the property owner's <br /> (requires written approval and Owner/Builder Verification Form signed and submitted). <br /> ave 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, o enter the above-identified property for inspection purposes. <br /> Applicant's Signature /"_ r / - /t/ <br /> Date-/--/e' <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:Wppliratlon Forms$HandoutsXHANDOUTMBuilding Permit Applicaflon.docPage 1 of <br /> (Re,Ased(07-08-10) <br />