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BUILDINGPERMIT MIT APPLICATION <br /> a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> Qui=B`aN 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 <br /> Project Address: <br /> Project Valuation: 3 S 15- iContact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: <br /> Address: e2,cb L '_ � C yU�, Address: <br /> City L,cG,k_Y State: Ci� City: State: <br /> ZIP: Ph#(jc�) S C 'cZIP: 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 /> M CompanyNanie: <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 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 DDnstntction. I authorize <br /> representatives of this city or county to enter the above-identified property for inspection purposes_ <br /> Applicant's Signature__ �� ( {t 4C U Q�t Date C <br /> 22 ,� 1f- <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:AApplimtIon Forms&HandoutslHANDOUTS\Building Permit Application_dmPage 1 oft <br /> (Revised(07-08-10) <br />