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°r4U'"" 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 /> ;FgR `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: I�rRC���� r,� v' ek, <br /> Project Address: t c/ `, lM y ' ( ( ✓ 1�lI <br /> ( -- <br /> Project <br /> Project Valuation: 50 (p" Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: fi7 0. a Name: p� <br /> Address: Ct E M Address: <br /> City: STCIAJ State: C,� City: State: <br /> ZIP: 2 t Z P h#( -I ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) 997,-4Y(�) <br /> Lic. No: T cl') � Z `j CompLany Name: .r r U t3L�r <br /> Address: 7 3 $ er e rFl/J b r ,O� City: J �f` P�/ St: CA 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 arriIS-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 construction. I authorize <br /> representatives 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 Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />