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i1 <br /> BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> " 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> c P` BUSINESS PHONE: (209)468-3121 <br /> q�)fipRN� INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATIQN.MUST BE�COMP,LETELY FILLED'OUT BY THE:"APPLICANT IN:QRDER TO-APP,LY`FOR' <br /> BUILDING PERMITS. <br /> Scope of Work: , <br /> Project Address: led _ <br /> Project Valuation: Contact E-mail: a� <br /> OWNERsN%gME'ANO ADDRESS gpPLICANT'NAME-ANp ADDRESS; <br /> Name: <br /> I L/ k Name: Ofto <br /> Address: 6—,3(l iAJ Sntod Address: /S- <br /> City: r State: City: State: <br /> ZIP: u/ ` Ph#�p�') �� <br /> CONTRACTOR.JNFORMATIOW Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION;. Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> L'ENDINGAGENCY. Ph#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder' Yes K7NO❑ 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-C6NSTkUCTIOK PERMIT APPLICANT <br /> By my signature below, I certify to one of the following: <br /> I am ❑ a California licensed contractor or❑ the property owner orx-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 /> 1 agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize <br /> representatives of thiycecklists <br /> unty to enter the above-identified property for inspection purposes. <br /> Applicant's Signature [:tSL C� Date o <br /> For your conveniendetailing any additional submittal requirements for various building permit type`s <br /> are available at the ivision counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:\Application Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 r <br /> (Revised(07-08-10) - "' <br />