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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 />Scope of Work: <br />Project Address: <br />Project Valuation: <br />Name: <br />Address: <br />ZIP: <br />Lic.No: <br />Address: <br />Lie.No: <br />Address:/5"/'t <br />Company Name: <br />Address: <br />Permit will be issued to an "Owner-Builder"Yes OO-.No0 <br />If yes,a completed Owner-Builder Verification Form must <br />be signed and submitted along with copy of the owner's <br />identification prior to issuance of the building permit. <br />Contact E-mail: <br />Name: <br />Address:I$"I Y <br />City:M ,J.t:1"f.o State:Ct4 <br />ZIP:'1S"~ro <br />Ph#() <br />St:ZIP: <br />khIJ", <br />St:('4 ZIP:~f~J'D <br />,.-'.-,-..',' <br />~.'.•~"f,I <br />Identification Number: <br />By my signature below,I certify to one of the following: <br />I am 0 a California licensed contractor or 0 the property owner or2-authoriz~d 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 ~~Date~+-(~=-<-.J/Iw.(-=-,,_ <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 &Handouls\HANDOUTS\8uilding Pennit Application.docPage 1 of 2 <br />(Revised (07-08-10)