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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 BY THE APP.LlCANT IN ORD.ERTO AfiPL Y FOR <br />BUILDING PERMIT~...'..'.' <br />Scope of Worle Ale.w e-")F !( <br />Project Address:q5~7 t:(!.O/>PERLJ pot:./5 <br />Project Valuation:9&')/.J~-Contact E-mail:/rmC'fqnltA/e r eholh?t:J//;-co ~ <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:-J05E MillY e:0 Name:7/VnA-G efiWe:-r <br />Address:/~/7 f.ffrjUrJ 0 It/.Address:2.1789 6n:"en6'r/a r Rei. <br />CitY:J/t;~1o r../State:CA-City:t/.~State:e4 <br />ZIP:Ph#()ZIP:q.5'~5-;L Ph#(tlO1)'11.;2 -S-3.=?o <br />CONTRACTOR INFORMATION Ph#() <br />Lie.No:Company Name: <br />Address:City:SI:ZIP: <br />DESIGNER INFORMATION Ph#() <br />Lie.No:I Company Name: <br />Address:City:SI:ZIP: <br />LEN'bING AGENCY Ph#() <br />Company Name: <br />Address:City:I Sf:ZIP: <br />Permit will be issued to an 'Owner-Builder"Yes 0 No 0 OPPICIAL'USE;::9NLX'~:J"':'-:{~'::',,.~.....-, <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 0 a California licensed contractor or 0 the property owner or2 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 ~p~~4 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:lApplication Forms &Handoutsv-iANOOUTSIBuikjing Permit Application.docPage 1 of 2 <br />(Revised (07-{)8-10)