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BUILDING PERMIT APPLICATION <br /> 1L <br /> a' 2a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> L/FOR <br /> THE APPLICATION;MUST BE COMPLETELY=FILLED'OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of work: &S AW AM2el h,4� 147✓" U�� O� 3// � a0xrW4,,k7Aa� <br /> Project Address: /11/ E rd O&IMM45 <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: LE 1/L/fG�2 <br /> Address: C Address: <br /> City: L I I State: LIA City: 1514hldd State: PA, <br /> ZIP: ,j- Ph#(,],t) ) J ® G 3 ZIP: J-3kf Ph#�,bl) ffo- <br /> CONTRACTORINFORMATION Ph#( ) <br /> Lic. No: Company Name: adAy1 2 <br /> Address: City: St: ZIP: <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 0 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 I unty to enter the above-identified property for inspection purposes. <br /> Applicant's Signature U Date ry«1/ 1 <br /> For your convenience c ecklists detailing any additional submittal requirements for various building permit types <br /> are available at the Bull ding Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:1Application Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />