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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:/5/.l..vJ Ktl5t7 Jet .,J/l Ave 5'pvHtlY1 C/7 9'>2t'tf <br />Project Valuation:Contact E-mail:CAnna.hk-rnr1q @yc~h(Jp C ZT7Y\ <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:i-Pl4 !<pS e f ~/tV'v5Ju.:p Name:Hfi(Ch J-l-S/A TaI1 q (fa~-v) <br />Address:/tJ/9p 5 -r~VA A/e.Address:/IJ/<JP s.Ttdw Ave. <br />City:C .;.;pgCt;M)State:CIJ City:(CA-{J.e4 ;n o State:(,/-1 <br />ZIP:95-(Jltf Ph#(rp8)_Q~~/6 3>-ZIP:9J;7)/<I Ph#(foS)],V ~-//,j ..>- <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St:ZIP: <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 D No D 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 D a California licensed contractor or ~e property owner or D 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 ~/~~0b~~L Date <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:\Application Forms &Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)