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BUILDING PERMIT APPLICATION <br /> SAN 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 FILLED OUT BYTHEAPPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: . <br /> Project Address: 1'18 S'. <br /> Project Valuation: `Jj>e Contact E-mail: j rPu1 erg. <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: t Name: Li — <br /> Address: r7 * I'K- Address: <br /> City: S ate: . . City: State: <br /> ZIP: 1*�Ic> P h#(21 ) Prv,6a2 ZIP: gra , Ph#(2 ) }' _ <br /> CONTRACTOR INFORMATION Ph#(2c1 ) E41-21a�?�,, <br /> Lic. No: Zr Company Name: <br /> Address: y ,raa �, City: st: ZIP: � l <br /> DESIGNER INFORMATION Ph# ) r -t�lL� <br /> Lic. No: baa Company Name: . <br /> Address: _2 ( J, City: st:(,_„A, ZIP: <br /> LENDINGAGENCY Ph#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permitwill 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 BYCONSTRUCTION PERMITAPPLICANT <br /> By my signature below, I certify to one of the following: <br /> I am 0 a California licensed contractor or❑ 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 /> agree to comply with all applicable county ordinances an state laws relating to building construction. I authorize <br /> representatives of this city or county to enter the above= ntified property for inspection purposes. <br /> Applicant's Signaturet - ' Date `I <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&HandoutMANDOUTME301ding Permd ApplicatloadocPage 1 of 2 <br /> (Revised(07-0&10) <br />