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P <br /> BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> »: :< <br /> 1810 E. HAZELTK9 <br /> BUSINESS PHONE: (2 9) 4 83121 <br /> o4CtFOR�" f 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: Z;7 <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: �: 7 "��E � > Name: <br /> Address: .- �-`� Pi Address: 1 c <br /> City: State: o City: Stater <br /> Ph#( GJ `d'__S -C5_5rP, " ZIP: <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> tc filo: ompany a <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> CompanyName: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes ❑ No ❑ OFFICIAL USE ONLY r, <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 WKe property owner or ❑ authorized to act on the property owner's <br /> (requires written approval and Owner/Builder Verification Form signed and submitted). AN <br /> b <br /> �v <br /> I ttiaye read this construction permit application and the information I have provided is correct. <br /> r <br /> 2gYee to comply with all applicable county ordinances and state laws relating to building construction. I authorize <br /> Lsentatives of this city or county to enter the above-identified property for inspection purposes. <br /> gnature Date <br /> c fivenience the lis s e Nina any additional submittal requirements for various building permit ty " <br /> at the Building Division counter. Demolition permit and mobile home on foundation require cheefr <br /> f <br /> T <br /> a �douts\HANDOUTS\BuiId!ng Permit Application.docPage 1 of 2 _ <br /> GK;; <br />