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BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 6x+ { 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> "<i 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: fiG17�hTOiJr 4 <br /> Project Address: 3S Vpr, /fJjltl <br /> Project Valuation: o o o Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> -Name: [,.�' J �r°tr veOpr Name: ( (.i ,�5 <br /> Address- .�J Ss�j S. d>t j�eV Address: _ "�� Z ( ilp1 7. <br /> City: State: City: rl State: (' <br /> ZIP: z7�� Ph#( tr,) 3 I- s .G) ZIP: fi 3U <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Ci L� z Company Name: t > (C TA C. <br /> IP: <br /> 2 <br /> Address: '� p c � City: �' ,� St: �� Z `) J <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 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 /> 1 am N/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 relafing.to building construction. I authorize <br /> representatives of this citityy or co/untyy to enter the <br /> /above-identified property for inspection purposes- <br /> Applicant's Signature 9 d b id0L j /y'•L Date 2J-1 11-1 <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:VApplimbon Forms&HandouMHANDOUTS\Building Permit Appiimfion.docPage 1 of 2 <br /> (Revised(07-08-10) <br />