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BUILDING PERMIT APPLICATION <br /> a• ' x SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> vi. 1 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: QOWERTI1 G �'N(Z✓•l.G` E � fl l /l EMP�•O & o U S E <br /> Project Address: 12 , A()STi IJ V 0 MA CA C 3 <br /> Project Valuation: ZCj ,QQD Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: SRNrINGO A MflNA VALW CJA Name: SROTIAGO MARIA VALFW14 <br /> Address: "2 Q �U S` 0 I`,D Address: , R 2 O S_ U ST INJ 9b <br /> ZIP: S Ph#( ZIP: Ph#fvpn) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lia No: Company Name: <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 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 ❑a California licensed contractor or tK the property owner or P 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 /> F:\Application Forms&HandoutsVHANDOUTS\Building Permit Appliration.docPage 1 of 2 <br /> (Revised(07-08-10) <br />