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ep0.U`" BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E.HAZELTON AVENUE,STOCKTON CA 95205 <br /> r. BUSINESS PHONE: (209)468.3121 <br /> Cq(rpeRN�P 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: Single family 2nd dwelling attached 4 car garage <br /> Project Address: cottsdale Rd. Lodi, CA 95240 <br /> Project Valuation: $750,000 Contact E-mail: millerconipany@yahoo.com <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Suchdeep Sams Name: Kris Miller <br /> Address: 3900 Scottsdale Rd. Address:4!�K(_ 4'®, <br /> City: Lodi State: CA City: _]_State: <br /> ZIP: 95240 Ph#( ) ZIP: �! �_ Ph#(?_09)981-6343 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: OWNERIBUiLDER <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#(209)478-4013 <br /> Lic. No:C-20384 Company Name: San Joaquin Design Group <br /> Address: 7877 N. Pershing Ave. City:Stockton St:CA ZIP:95207 <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 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 N 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 en ter the above-i ied property for inspection purposes. <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 /> FMpplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-09-10) <br />