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BUILDING PERMIT APPLICATION <br /> ti <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 /> LieoT+ <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THEAPPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: QW, 1JO�� <br /> Project Address: ] ;h Lln <br /> Project Valuation: �,? �i( _ Contact E-mail:kk (� <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: NcA(CV-\- UX0CL Name: �t '5AkTLA I: .-1 4kl�u <br /> Address- 5114 (d), � Address: .,Q <br /> City: ��( State: City: State: <br /> ZIP: Ph#(,5s� (w s ZIP: Ph#(2A) SM-23113z— <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION 2 <br /> Lic. No: �� jq� Company Name: \ ( l ' G— 4JC . <br /> Address: �, � (04l 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 ❑ 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 owners <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 Xauthorized 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 per)'taoplication <br /> and the information I have provided is correct. <br /> I agree to comply with all applicaunty ordinances and state laws relating to building construction. I authorize <br /> representatives of this city orco enter the above-identified property for inspection purposes_ <br /> �r9 r <br /> Applicant's Signature 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 /> r FA Application Forms&Handouts\HANDOUMBuilding Per It Appllcation.docPage 1 of 2 <br /> (Revised(07-08-10) <br />