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BUILDING PERMIT APPLICATION <br /> v a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> q<iFgR?' 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: R'0 a-,f2- ' deli -b -_,;Woqf ergldtnuale I, 01 ve * I" <br /> Project Address: 56 863 0-0U.'e-t CA 9 530 AAA1.'1 la <br /> 7 a <br /> Project Valuation: 5 p �(� Contact E-mail: rk&vr6w?yo� OJAA <br /> OWNER NAME AND ADDRESS APPLICANTNAME AND ADDRESS <br /> Name: cionyvie C�v�d. Fl ( I Name: R.Oyi I [1� ' ' <br /> Address: �(}$6 3 � Address:�(69 3 I`-L L!k e"t <br /> City: State: ILA-1- City: tMet, State: <br /> ZIP: Ph#Vffi) 3 -()3d ZIP: Ph#(0) ' <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: 3S�S( � Company Name: E , t,L,�� (�_u� r d� <br /> Address: 1g�2 h- S�- 33 City: <br /> LENDING AGENCY Ph#(70 6 Q ( `?jq er-(j <br /> Company Name: <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 /> 1 am ❑ a California licensed contractor or❑ the property owner or Wauthorized 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 co �the above-identified property for inspection purposes. <br /> Applicant's Signature Date <br /> r <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 /> FMpplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />