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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 APPLICANT IN ORDER TO APPLY FOR <br />BUILDING PERMITS. <br />Scope of Work:W~W ~-t S /<h.i/1 c.:t <br />Project Address:z....SOS3 'Q.Q\I'«l2-d \G.s CiA..\<Sl--r CJA-C1Ss'60 <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:DO-v1 +-CeJ-c~t"(YYI OV I V)o Name:5:f}ME- <br />Address:2.c;0 s~'Do\/-€~d Address: <br />City:E\~a \Oh State:Cv::r City:State: <br />ZIP:%:QD Ph#(d)~)~S ~--7'(,()8 ZIP:Ph#() <br />CONTRACTOR INFORMATION Ph#() <br />Lie.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:~~G-~~~ <br />Address:City:Y\'LO d.e.s tv St:C(4--ZIP: <br />Permit will be issued to an "Owner-Builder"Yes ~o 0 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 0 a California licensed contractor or ~the property owner or 0 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 />representativesof this cityraun7LbOVe.identifie~propertyfor inspectionpurposes. <br />Applicant's Signature QI A I t7J/,{)U./L'L.-Date 7~l-'+-.'l't <br />liP,;v-For your convenience checklists detai ng 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:\BUILDING\HANOOUTS\8uilding Permit Application.doc <br />(Revised 1-23-09) <br />Page 1 of2