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BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468-3121 FaRa," INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDINGPERMITS. scope of work: '2 KUD MCN3 OF Wi) MD, V W�L 5-1 UL Project Address: LDS01%,�_, W ATEAa1)0 IM. CST H-LWKulSS) STMM) ,CA,9.51 S Preject Valuation: 1Sc',O(m,ar�) Contact E-mail: C[�ELS®IAM ® N6-1 min OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: Name: TWE CHILL-c Al ) Cb. Address: f,L972_ F I U)AT V_LM POIZ40 Address: q MfL ELLj ST City: STMLTC)i\) state: M, City: ��_FDCJr'T©n State: CP� ZIP: Ph#QLR 931 - C)Igq ZIP: 9SI Ph#(289 CONTRACTOR INFORMATION Ph#QLCf)gSrj-Slll?) i Lic. No: 'JR3(D1Z�,S Company Name: C_HE�LSDRW Cf), Address: t-(?DS M[_J_EL�) City: 1DT_T_7_TM St:CL._ ZIP: q5 Z1c1 DESIGNER INFORMATION Ph#�� Lic. No: [Dr Company Name: ^[ CA�rLS[)ffiW C.C)., Address: LA?n-,' CS VLLgLOJ ST. City: ISMCM-�) St: CR, ZIPriSZl9i LENDING AGENCY Ph#( ) Company Name: MD*E Address: City: St: ZIP: Permit will be issued to an "Owner-Builder" Yes ❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to one of the following: I am 4 a California licensed contractor or ❑ the property owner or ❑ authorized to act on the property owner's behalf (requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the information I have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Applicant's Signature 1)-" V1S46,�� Date Lb/5/1H For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. FApplication Forms&Handouts\HANDOUTMBuilding Permit Application.docPage 1 of 2 (Revised(07-08-10)