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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:P~;'J-L~~)'D"~~~:D~~p~~ <br />Project Address:3552 '/oseJr1ilt:/Jv~.>/.-.•7F?CA.~ <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:Ra.~bl6-~'l"\~~h~Name: <br />Address:3 ~v5"2 '(OS-e ~l-l .Av~Address: <br />City:~~State:CA City:State: <br />ZIP:Ph#(z.o1)g'3"2 -7lt44 ZIP:Ph#() <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St ZIP: <br />DESIGNER INFORMATION Ph#(2d~)5 ?8'-t>65 I <br />Lic.No:C 2.7:5"31 Company Name:~~~- <br />Address:I$"Z3Vj'~~C:r-City:S-J..c r k:~,St CA ZIP:~S2tJ7 <br />LENDING AGENCY Ph#() <br />Company Name: <br />Address:City:St:ZIP: <br />Permit will be issued to an "Owner-Builder"Yes 0 No 0 OFFICIAL USE ONL Y <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 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 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 penn it types <br />are available at the Building Division counter.Demolition pennit and mobile home on foundation require check- <br />list. <br />F:\BUILDING\HANOOUTS\Building Pennit Application.doc <br />(Revised 1-23-09) <br />Page 1 of2