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BUILDING PERMIT APPLICATION <br /> r SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> ' BUSINESS PHONE: (209) 468-3121 <br /> c4<ikB' N P ( 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 Work: 141 , 0 <br /> Project Address: 71& u�i�c�l �• S��fe CG <br /> Project Valuation: n 30,0 r Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ntot\10 0A SetL162, Name: �nlo,i� GO.t5IrIe'a. <br /> Address: ' _726 WY(0(T Pt . Address: 70 19W,-l6% W- <br /> City: 1510A'0i4 LPhff(jort) <br /> e: n City: <br /> ZIP: 5021 `J 2 g 519 ZIP: 952/ Ph#(Z ) 2`15-7588 <br /> `CONTRACTOR INFORMATION Ph#(53,D) 16?8 - X7-77 <br /> Lic. No: 911 '� �60o Company Name: 011'Al- 14e411 ui/ 41 1 ANG- <br /> Address: Zjo 0&1 Ilw City: 9xWa(� st: Cof ZIP: 9595,5- <br /> DESIGNER <br /> 5 45.5DESIGNER INFORMATION Ph#(t-)3o) N38 ` 777 <br /> Lic. No: Company Name: UyiL 2tq u; i 1. C. <br /> Address: <br /> &a ytvV Qq City: Mav,,,e(( St: Cr4 ZIP: 95R55 <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 BYCONSTRUCTION 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 El 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. <br /> Applicant's Signature ate <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:\Application Forms&Handouts\HANDOUTS\Building Permit Appiicalion.docPage 1 of 2 <br /> (Revised(07-08-10) <br />