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BUILDING MIT APPLICATION <br /> 4r SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ;G n <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> ' BUSINESS PHONE: 209 468-3121 <br /> 4<iko'R�� INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLEDOUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: t' llc to 3& 2a(/o nc? r{ aW/f A /0 rd"[rtet GdW-* �c <br /> Project Address: <br /> 1117,5- 7 /j✓, 1-1) -CAI S Z. 00/ Cx 9S 7V_ e- <br /> Project Valuation: Contact E-mail: <br /> OWNERINAMEANDADDRESS APPLICANT NAME AND ADDRESS <br /> Name: 12013&72 9 7C91e)/r/ Name: �619&''7ZjAddress: l(7S -S' 121), Address: 175 T / VCity: Z0,0 : � City: G (2�7 StatZIP: S C'2" ) �J.-303 ZIP: S Z Ph#(Ze <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: +Ph4( <br /> ty: St: ZIP: <br /> LENDING AGENCY ) <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 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 1,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 3 41- <br /> For your convenienc 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 /> ::Wpplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> Revised(07-08-10) _ <br />