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BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468-3121 C��rFOfR��P INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: sNS 7,r?/ 4 Project Address: �� V� � OA. 9S3,0 Project Valuation: Contact E-mail: d gdL �j OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: 1+M4 FYZo L Name: Address: /gyp / S R&�jX fl�. Address: W/ 8_1Pd City: 'j fje y State: eA- City: S State: eW ZIP: �530� Ph#(ZL I) 6�1]'/�i/ I ZIP: 9536f lPh#�W)W, ' 7z__7' CONTRACTOR INFORMATION FP h#( ) Lic. No' I ompany Name: Address: fe yr City: St: ZIP: DESIGNER INFORMATION Ph#( ) Lic. No: Company Name: Address: City: St: ZIP: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder" Yes WNo ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: 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 ❑ a California licensed contractor or❑ the property owner orauthorized 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 I 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 or ounty to enter the above-identified property for inspection purposes./ / Applicant's Signature �C LI -/lGr Date V,27/43— For your convenience hecklists detailing any additional submittal requirements for various building permit types are available at the ilding Division counter. Demolition permit and mobile home on foundation require check- list. MApplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 (Revised(07-08-10)