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BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> yi { 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> c"L'iFOR `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: 2 — - <br /> Project Address: gig S, P,IP D Rb <br /> CA.9534- <br /> Project Valuation: 05, 0-00, 63 Co tact E-mail: <br /> OWNER NAME AND ADDRESS .�Uk Cv APPLICANT NAME AND ADDRESS <br /> Name: Name: S <br /> Address:Z--B 0S � � Address: <br /> city,�G ,State: City: MaidtState: <br /> ZIP: 9530 I Ph#(.?0Q) 'aj21- 5_ '7 ZIP: �S Ph#(�j Y-3 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> 26 <br /> Lic. No: Company Name: <br /> Address: City: St ZIP: <br /> DESIGNER INFORMATION Ph# <br /> Lic, No: Company Name: 5vf �\j�� � ��(�E"t 5k2 (C�® <br /> Address:->& & 67-e City: St.r al- ZIP: l <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❑ 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 ;�LG7 Date <br /> For your convenience checklists detailing any additional submittal requirements forvarious building permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:Wppliration Fortes&Handoufs\HANDOUMBuilding Permit Appllcation.docPage 1 of 2 <br /> (Revised(07-05-10) <br />