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BUILDING PERMIT APPLICATION <br /> ,j 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 /> 9�1FOR <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: 01010a o oC .--wo <br /> Project Address: Z3 <br /> C ,✓ <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: �UTo stCA Uo Name: <br /> Address: _ 3 L ran (/?a Address: <br /> City: o�t�trntJ State: City: State: <br /> ZIP: 95Z .S Ph#(20 ) S(g- 693 ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> I <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 'h#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder" Yes JK 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 /> 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_ c7 <br /> Applicant's Signature��5 /W11 Date ' 2% L__ _y_ <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 /> v� tisk <br /> v`Iteylion Forms$Handouts\HANDOUTS1130ding Permit Application.docPage I of 2 <br />