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ip <br /> BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> 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: <br /> Project Address: < <br /> Project Valuation: <br /> '� "> , � Contact E-mail: Cc" <br /> OWNER NAME AND ADDRESS APPLICANTNAMEAND ADDRESS <br /> Name: Name: _13_�xc" L ria <br /> Address: 4> (AL p�L t Address: c, c.0 <br /> City:' State: City: r —, State: C <br /> ZIP: c�3g: a Ph#(2�q ) 't �,dfv7 ZIP: Q Ph#(Zct ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: a3 c;(g4l j Company Name: <br /> Address: �3tJ� A iZY'tt-v✓t� UJ City: —00 St:t,,� ZIP: 'J ; <br /> DESIGNER INFORMATION Ph#(2-i) t c; 24 Z 7 <br /> Lic. No: Company Name: <br /> zN <br /> Address: 1 t 4_ City: � St: ZIP: ; < <br /> Ib`L� rr-; �- �i� <br /> LENDING AGENCY Ph#( ) <br /> Company Name: t�-- <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 BY CONSTRUCTION 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❑ 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 t i' pate -d / <br /> For your convenience ch cklists detailing any additional submittal requirements for various building 4ermit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:1Application Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) - <br />