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BUILDING PERMIT APPLICATION <br /> y { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> 9Cieoai'� INSPECTION REQUEST-24 HOUR RECORDER: (209) 46B-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: � _ d , <br /> Project Address: c/ . <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: �� .� y� Name: !cr At! i e- <br /> Address: Address: o, <br /> City: L-,,4- State: c4 , City: 1Crke;16 State:C4 <br /> ZIP: Ph# j s 3 37(o I ZIP: Ph#q ) � -� � <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: ff rCompany Name: •Sn,' G Di1 $�I C <br /> Address: �r /J �� � City: oh— S12 ZIP:5;1 <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 r 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 ordin ces and state laws relating to building construction. I authorize <br /> representatives of this city or county to enter th ove-identified property for inspection purposes. <br /> Applicant's Signature Date �J//� <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&HandoutslHANDOUTSIBuriding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />