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°PGur" BUILDING *PERMIT APPLICATI®N <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> a I'` BUSINESS PHONE: (209)468-3121 <br /> LlcoR� 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: q s E_ T2 Jnc //L X'C l_ Abu/ A-rT>3 <br /> Project Address: <br /> Project Valuation: 7Z 6ik1 Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: <br /> Address: Lr r `Z —,� Address: l <br /> n�lf f <br /> City: (� State: City: s State: <br /> Ph#( ) ZIP: S S7 PhIl") y lO <br /> CONTRACTOR INFORMATION Ph#QWP C/ I <br /> Lic. No: �S _ Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION <br /> Lic, No: /q ' 'r- I Company Name: <br /> Address: j C iz / City: Vc Mem St: I ZIP: �{�4> <br /> LENDING AGENCY Ph#( ) <br /> Company Name: J <br /> Address: p City: St: ZIP: <br /> Permit will be issued to an °Owner-Builder' Yes E] No-�l 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 /> By my signature below, I certify to one of the following: <br /> I am a California licensed contractor or El 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 comy ordinances and state laws relating to building construction, I authorize <br /> representatives of thiscityor county ennt the ove-identified property for inspection purposes, <br /> Applicant's Signature Date—q/_7 <br /> i <br /> For your convenience checklists detailing any additional submittal requirements forvarious 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$HandoutslHANDOUTS1Building Permit Applin tion.docPage 1 V2 <br /> (Revised(07-08-10) <br />