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ultv BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT �I16 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 M BUSINESS PHONE: (209) 468-3121 �d«FORi" 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: W" ftl(,Olt-44 �1�IDITIO�I Project Address: 024,-7 S4 E >-c-Sc~tJ I C . Project Valuation: 5 ,cd0 Contact E-mail: OLYCIVIoviW+ III. (� •V1B OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: mvvy'tlt +;Mvei q.t Name: V11~ A/1E,"17 V" )VIC. . Address: 02,10f"J 5-Of E • Mx%1W1"a • Address: &0 41 1S-•I't ST City: esjral6 1 State: C,.A. City: MO,p4!5;,� State: CA- ZIP: �y"}i�d Ph#(461 0-n• 01I¢ ZIP: g53s'4+ Ph#( si-i—&it4 CONTRACTOR INFORMATION Ph#(Z69) 993-g? Lic. No: 0 6x"4.07!0 Company Name: P.90tr , dil/USC-4 �.?�. Address: 'k City:M^oiJ st:Gt4 zIPAIs374 DESIGNER INFORMATION Ph#( J42r 5107 Lic. No: G to b Sl Company Name: WI k Sort ^WXt t J-kW 1 n Address: (pd q tsom s1' City: P%ftjoewTh st: Cok , zIP:QS LENDING AGENCY Ph#rjo6]�t Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder' Yes ❑ NO^ 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 or)<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 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 county t ent - ove-identified property for inspection purposes. Applicant's Signature Date—LIQA 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. FAApplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 (Revised (07-08-10)