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4P BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468-3121 INSPECTION REQUEST -24 HOUR RECORDER: (209) 468-3165 F:\Application Forms & Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 (Revised (07-08-10) I nc ArrucA l 1UN MUS I BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS.: Scope of Work: Ueci l3e�rt�n Project Address: / S 3e, Ct H k Ro o YD,ti Project Valuation: Contact E-mail: OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: Name: /41 eel2/A c.w Address: S ( o{ 4 le Address: City: — State: City: gcj . State: ZIP: ZIP: Ph#(d vi) `if4-680.5 CONTRACTOR INFORMATION Ph#(ate;) Ggc, S Lic.No: (,3�-�s� Company Name: l'ar�N2Hc.4 Lo s)K�c-�ioN Address: S"SU ^ " i- Saw { City: 1�,C jk St:Cgt ZIP: rl S`30y DESIGNER INFORMATION Ph#(,200) Q ru - (, 6 o 5 Lia No: Company Name: (' Of 0-k C o/ -r s! R-0 C. i �'Q -f Address: S7 So "V- 5✓�e� : 13c i q St:Cq, ZIP: 0.S 3o<j LENDING AGENCY ) +.Ph#( Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner -Builder" Yes 0 No ❑ OFFICIAL USE ONLY Identification Number: If yes, a completed Owner -Builder Verification Form must be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT_ APPLICANT By my signature below, I certify to one of the following: I am [0 a California licensed contractor or ❑ the property owner or 0 authorized to act on the property owner's behalf (requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the information 1 have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize representatives of this city/orrrcoounty to enter the above -identified property -for inspection purposes. lV "` Applicant's Signature i ( C----- Date ) )-- & - 13 For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. F:\Application Forms & Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 (Revised (07-08-10)