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�AGUi" BUILDING PERMIT APPLICATION <br /> ,J. u SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> u 1814) E.HAZELTON AVENUE,STOCKTON CA 95205 <br /> •. BUSINESS PHONE: (209)468-3121 <br /> P;go INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165- <br /> THE <br /> 68-3165THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THEAPPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: QloowtiWA;011 <br /> Project Address: 6L <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> -Name: q 0. Name: <br /> Address: IQ Sq ll 0 pyl(� Vim- Address: <br /> city: 0 olc_A—i✓t State: (f' City. State: <br /> ZIP: 26Ph ) 9�& 15 1 ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lia No: Company Name: <br /> Address: uy: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic, No: Company Name: <br /> Address: City: St: ZIP: <br /> L <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address: City: St ZIP: <br /> Permit will be issued to an "Owner-Builder" Yesbd'No[_1 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 owners <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{gthe property owner or J]authorized to act on the property owner's <br /> behalf(requires written approval and Owner/Builder Verification Form signed and submitted)_ <br /> I have Te-ad this construction permit application and the information I have provided is correct. <br /> I agree to complywith 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 SLltoZC,) J <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 /> F:Vapp11mt1Dn Forms&HandoutslHANDOUTS1Building Permit Application.docPage 1 oft <br /> (Revised(07-08-10) <br />