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C <br /> 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 /> c9(jFo'�N�P 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 /> , <br /> Project Address: 11-(�e>( 4.1 <br /> Project Valuation:R,31, 00U Contact E-mail: 9-ft4-C cr y u.j. <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ;� Name: h r Df z- <br /> Address: t5—Gal f Address:( 2 <br /> City: O State: K City: c State: <f <br /> ZIP: j 6 1 Ph#Qa/} 5_7T-? e/j ZIP: 1�7 (, 1 Ph#&�) of 6—d(20 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: 6 f r Company Name: �IN lu 1 <br /> Address: G_Cf ` u_)*; & / PI&c_ City: St:dk ZIP: I f 33, <br /> DESIGNER INFORMATION Ph# q) <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 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 1A a California licensed contractor or❑the property owner or❑ authorized to act on the property owner's <br /> behalf Irequires 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 the above-Identified property for inspection purposes. <br /> Applicant's Sig 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 /> 17:1Appllc fion Foms&HandoulslHANDOUTWullding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />