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BUILDING PERMIT APPEDEPARTMENT N SAN JOAQUIN COUNTY COMMUNITY DEVELOPMEN 1810 E. HAZELTON AVENUE,ST0005BUSINESS PHONE: 1 INSPECTION REQUEST-24 HOUR RECORDER65, THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS, Scope of Work: Project Address: 7, Z 1 G�1 Project Valuation: Contact E-mail: OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: /7. P Name: Address: Address: X11 City: " State: G� City: State: ZIP: Ph# ZIP: Ph#( ) CONTRACTOR INFORMATION P #( ) Lie. No: Company Name: Address:. City: St: ZIP: DESIGNER INFORMATION Ph#( ) Lie. No: Company Name: Address: City: St: ZIP: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder" Yes ❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my-signature below, I certify to one of the following: 1 am❑ a California licensed contractor or the property owner or❑authorized to act on the property owner's behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the information I have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-Identified property for inspection purposes, Applicant's Signature / Date —) For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. FA\Appiication Forms 8 Handouts\HANDOUTS\Building Permit Applimiion.docPage 1 of 2 (Revised(07-08-10)