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°'" BUILDING PERMIT APPLICATION <br /> )��..sf.c�L <br /> zi — <br /> � `?� SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ` 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> °4' -•N r INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> �JFOR <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: ? 6 2 <br /> Project Valuation: ntact E-mail: <br /> OWNER NAME AND ADDRESS n APPLICANT NAME AND ADDRESS <br /> Name:. r (� T 4 ,S W__ Name: Sl /-O-TA Sp tG/)/- <br /> Address: ( j 3S L7 !1 J w Q Address: 11356 14fOA 12 C� <br /> City:MoqStateA C CA City: E? State: <br /> ZRq5_ 3'3& Ph#(Pb'h '7LV -Z7 of ZIP• �(� Ph#()o Z Z7LA <br /> CONTRACTOR INFO TION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#�r " ) 2 <br /> Lic. No: A����� Company Name: �y' <br /> Address: 35 z ' G -3e city: ' C`= st: zip: gg,26a <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 a property owner or ❑ authorized to act on the property owner's <br /> behalf(requires written approval and Ow r/Bui der 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 unty to enter the above-identified property for inspection purposes. <br /> Applicant's Signature Date <br /> For your convenience klists 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& Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />