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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 />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:>ADO ITIDrJI ~'1 fo tEl "JI •••.V ~IC ~AM II"~}::_~I("')1:,,1L.c <br />Project Address:2.1"131 rE..RCA ty eo RO <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:.)/M j)5T~GI£.HArJ~DN Name:GH e~66t-4 eM ec Aeu..I UJ (l P <br />Address:P,O.~x 577 Address:-33~O OE1=..e PAea:::oe SU'IF.E <br />City:L.L£Mf.fUI~State:CA City:5'-Ot'A~.To N State:LA <br />ZIP:t16Zz..7 Ph#(2L>1)U /3 ~Z:14!f 3 ZIP:t1621q Ph#(ltfl)Cf6lP 1..16 u/~ <br />CONTRACTOR INFORMATION Ph#() <br />Lie.No:Company Name: <br />Address:City:St:ZIP: <br />DESIGNER INFORIVIATION Ph#(ldj)'16LP ~t:;/ol D <br />Lie.No:Company Name:Crte.0 ~eJ M PL rq 12C.-4 •C.I)flP. <br />Address:33~O OG(E.e ?Aek'O~~I ('t==~City::)T60k:rorU St:tA ZIP:'16Z1'1 <br />LENDING AGENCY Ph#() <br />Company Name: <br />Address:,City:St:ZIP: <br />Permit will be issued to an "Owner-Builder'Yes D No D OFFICIAL USE ONLY <br />It 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 PE:RMIT APPLICANT <br />By my signature below,I certify to one of the following: <br />I am 0 a California licensed contractor or 0 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 aU applicable county ordinances and state laws relating to building construction.I authorize <br />representatives ot 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 pennit and mobile home on foundation require check- <br />list <br />F:\BUILOING\HANDOUTS\Building Permit Application.doc <br />(Revised 1-23-09) <br />Page 1 0(2