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BUILDING PERMIT APPLICATION <br /> Q a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> °a•-_i:i:• 4 INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> Lt FOS <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: t <br /> Project Address: `ot"1 (p N _1)UACA,4 <br /> Project Valuation: 7-5 01600 Contact E-mail: -6".Al-tJoad( e(_J N+f- <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: ­5gyj lc1Z V✓ /art <br /> Address: )cj-I{f, P,1 Address: 1' T_ <br /> City: State: 64 City: State: C�4 <br /> ZIP: Ph#(2 &6_ , 2`$Zj ZIP: q 5-Z_'A'L <br /> CONTRACTOR INFORMATION Ph#(,r�_C{� — <br /> Lic. No: Pj L J Company Name: 5 a_C,-.1 1 y( ��Q vrVa At 0��' <br /> Address: 1 '5(p0 A4i(( 57(4v � City: UC)CT St:C ZIP:rj5 f 2 <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 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 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 Ithe above-identified property for inspection purposes.. <br /> Applicant's Signature Date V 2 20a <br /> 3 <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:Wpplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />