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o BUILDING PERMIT APPLICATION <br /> Q SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> °ti Fonr`� INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: <br /> Project Address: ( ZgC7 j r (�°;r-.- Yh V /c <br /> Project Valuation: dv� Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: f�-A {[/j14" Name: @� <br /> Address: . Z F_ �r Address: Cj L <br /> City: S rGt State: n® City: state: <br /> ZIP: (:� 5,-Z,( Ph#( ) ZIP: Ph#( ) (:�lU X794 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: -7 71 Company Name: ( } e <br /> Address: ��Cz City: St: OT ZIP: �i z <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. 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 E] No ❑ <br /> 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�4_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 /> I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or count ter the above-identified property for inspection purposes. <br /> Applicant's Signature � Date S' 3 <br /> For your convenience checklists detailing a y a [ 10 nal submittal requirements for various building permit types <br /> are available at the Building Division coup r. emolition permit and mobile home on foundation require check- <br /> list. <br /> F:\Application Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />