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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 COMPLETEL Y FILLED OUT BY THE APPLICANT IN ORDER TO APPL Y FOR <br />BUILDING PERMITS. <br />Scope of Work:j1}~J2--Fq~~ <br />Project Address:q~(b DIJDtgl e», <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:f?tJ8~f)1O !3()~/VPMtPO .Name:f~ro [3V¥WO?rP () <br />Address:.i«I u-a-cJJ 11tA'{r;;~~Address:q ~(p [)Vf)L-Fy'~~, <br />Cit'f?7'Q'~j..J State:Lb.-CityS~,u State:6A- <br />ZIP:'15'10(;:;Ph#(crB~01 '31 ZIP:qt-.2-Ph#(i80 -6r39 <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St:ZIP: <br />DESIGNER INFORMATION Ph#('(1Oq)qr:(-081"2- <br />Lic.No:C '2 7{)19 Company Name:A:{?~t1Fa-U~/* <br />Address:)0 l\7Tt2MPolct C{2-l~---Jo 71D'&~Wt0 sr CA-ZI P:Cf'S'2/):LCity: <br />~f1fNG AGENCY Ph#() <br />COmpanYNa~ <br />Address:,/City:St:ZIP: <br />Permit will be issued to an "Owner-Builder"Yes 0 No 0 OFFICIAL USE ONL Y <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 or~uthorized to act on the property owner's <br />behalf (requires written approval and Owner/Builder Verification Fo m 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 ~=-'t"Date tlu.j.Ujz.mr <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:\BUILDING\HANDOUTS\8uilding Permit Application.doc <br />(Revised 1-23-09) <br />Page 1 of 2