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BUILDING PERMIT APPLICATION <br /> / r' ij `•Ki SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> °gtrr one+` 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 W ork: �Iz1�1 o � k \61t• 11 s� FFw n /}7r7 TIT)o o/- 'K_� q-fj{2t- <br /> ProjectAddress: 1106(D .} AIQ�O(2�W/tsEe sz4Pwo uL <br /> Project Valuation: 3S o c c. Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: C-�K1-NNRO ��i'tES LIQ Name: <br /> Address: \ 30o S MLv—fNC,ky 4 ,- Address: �530D M SKINLfc ( I�F <br /> City: State: C/{- City: (_ T t} State: c/4-- <br /> ZIP: Ph#(a-C)`j 13S-18 ZIP: X53 L0 Ph#( 3)4-01d? <br /> CONTRACTOR INFORMATION Ph#( <br /> Lia No: ':(S`r( S(38 Company Name: pZt I{ STv} mitis; k/\C <br /> Address: 1�Sfv �✓�ltiHz�h� �� 3os city: MP r ) F CI- St: cri- 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 oruthorized 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 permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> FMpplication Fonns&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />