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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 /> d4••:.,-:::•��°' INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> ��foR <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work <br /> Project Address: <br /> Project Valuation: Contact E-mail e,) <br /> a <br /> OWNER NAME AND ADDRESS' APPLICANT NAME AND ADDRESS <br /> 1Name: <br /> Name: 1 iG(( �� ( �((nx^� �,5ctic rfis ��. <br /> Address: i:�CJ Address: <br /> - <br /> City: e' .yy, (eat State: tct City: (al e e)Vgq (-C-1 State: dA <br /> ZIP: ° .C) Ph#(201) '.`` ` t..(J ZIP: ( _ _t3 Ph <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. 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 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 ❑ 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 /> 1 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 (l 9+ (13e4 Date .�5 -- " o•— ) ;Z <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 /> FMpplication Forms&Handouts\HANDOUMBuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br /> r <br />