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p4u'" 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 /> 92;Fon�`" 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: 5006 <br /> Project Address: <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: <br /> c� <br /> Address: Address: <br /> City: State: CcL City: State: <br /> ZIP: 15Z D Ph#(zxr'y) 'S 6 ­70 S3 ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lig:No:' Company Name: <br /> Address City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lig Company Name: <br /> Awe City: St: ZIP: <br /> r _ , t[DING AGENCY Ph#( ) <br /> City: St: ZIP: <br /> P fo ap`OWner Builder' Yes ❑ No ❑ OFFICIAL USE ONLY <br /> If e d OGvner Butlde�VenfIgo ion Form must Identification Number: <br /> bei su(rfttted <br /> 910 ng qith ct py of.the owners <br /> d prior to Issuance'9 the bulliftng permit. <br /> DECLAR;4 O BY CONSTRUCTION PERMIT APPLICANT <br /> B y Stgtiatiire`below, I certify to one,of the following: <br /> ❑a California Licensed contractor qr" the property owner or Elauthorized to act on the property owner's <br /> efait{requires written approval and-Owher/Builder Verification Form signed and submitted). <br /> ( lave read this construction permit application and the information I have provided is correct. <br /> I agree to comply with lall applicable county ordinances and state laws relating to building construction. I authorize <br /> tepresentatives of this city or county to enter the above-identified property for inspection purposes. <br /> Applicant's Signature '' Date <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 /> FAApplication Forms&Handouts\HANDOUTS\Building Permit Appllcation.docPage 1 of 2 <br /> (Revised(07-08-10) <br />