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C5-5 1 <br /> °FG�rrf o BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i• -"R' :{ 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> t,Foa INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165- <br /> THE <br /> 68-3165THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE-APPLICANT IN ODER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: <br /> Project Address: 14 118 '-,rXVf6 12,OLAO t,.O eV CA gS2.147- <br /> Project Valuation: Contact E-mail 1Lyu(� (3cc, YK41 t vvn <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> -Name: t 10 It 4" RY-IfAfOY ei�)C(RJhr Name: <br /> Address- LI (J. D'ot'vig P-J, Address: Sh-ME NS nUNC- '1- <br /> City. Lo JA State: CA City: State: <br /> ZIP: �js� c{Z Ph#(��) iD'7?-3226 I ZIP: Ph#( ) <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: 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 ❑ 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 owners <br /> identification 1prior 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 /> Cam❑ 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 complywith 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 <br /> property for inspection purposes_ <br /> Applicant's SignatureGy LLQ � cL!UJ Date <br /> 77 - ) <br /> Foryour 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 /> first. <br /> F:%Application Forms&Handouis\HANDOUTS%uilding Permit ApplicabonAmPage 1 oft <br /> (Revised(07-08-10) <br />