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BUILDING PERMIT APPLICATION <br /> r SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> � f u <br /> . f. 181A E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> cam ' BUSINESS PHONE: (209)468-3121 <br /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THEAPPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: NS j a Yd = <br /> Project Address: �4us N <br /> Project Valuation: z• pbit, Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME D ADDRESS <br /> -Name: keti*is 3{A !\1 C— Name: <br /> Address: Address: <br /> City. State: City. State: <br /> ZIP: Ph# ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic, No: Company Name: <br /> Address: zff S� �ItTk4 St. ZIP:LENDING GENCY <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 owner's <br /> identification prior to issuance of the building permit <br /> DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br /> By my signature below, I certify to one of the following: <br /> I am❑a California licensed contractor ort—the 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:Applimfion Forms&HandouMHANDOUMBuilding Permit AppllcMon.docPage 1 of <br /> (Revised(07-08-10) <br />