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BUILDING PERMIT APPLICATION <br /> �oP. a.coc <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> „��, BUSINESS PHONE: (209)468.3121 <br /> q<iko'a�' 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. I' <br /> Scope of Work: con 116/scicjL T) - v{�✓ co✓silT Tic✓lLoo/� Ov✓ H�IDD J�IP S o6S �our/lF/+S <br /> Project Address: 6yss 5jvc11kcTC>0 G/ Z-0-7 <br /> Project Valuation: SS-01000 Contact E-mail:613of?-cHJ7ZnTEpNco>-j <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: 1z\TF At'9 Name: GRBC> 130IZC)tAp_M PY1 D6516U611.00,0 <br /> Address: 6 fSJ /)9GlC/L VeF Address: L11a?p 'rAA,1t :E 1- 1bC Ep #1410 <br /> City: STockTotJ State: City: F_vcKL ttJ State: cAr <br /> ZIP: 15_z07 Ph#('101) \-i7g_Sob 2 ZIP: 95677 Ph#(9)6 ) 226.5 V9S- <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: T 3.D. <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#(J)L) Z Z 6-S LJ $oI <br /> Lie. No:G-28Soy Company Name: 1PW1rUbSIC,0 GRouP Lt/c. )zv`f <br /> Address: I/L/90 YF1'A/IcrE-ell L- 14v #,Ino ' City:rzoC K t_IAl st:c,4 ZIP: clS6 77 <br /> LENDING AGENCY Ph#( ) <br /> Company Name: N fr <br /> Address: City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder'iYes ❑ 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 t'Y­-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 r, <br /> behalf(requires written approval and.Owner/Builder Verification Form signed and submitted). <br /> 1 <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 bove-identified property for inspection purposes. <br /> Applicant's Signature Date 2Cl b <br /> For your convenience checklists detarti any additional submittal requirements for various building permit types <br /> are available at the Building Division cot riter. Demolitionpermit and mobile home on foundation require check <br /> list. <br /> F:\Applicat(on Forms&Handouts\HANDOUTS\Build6Tg RermifApplication.docPage 1 of 2 <br /> (Revised(07-08-10) <br /> F <br />