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BUILDING PERMIT APPLICATION N ?{ SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468-3121 cd•• ° INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 «FOR THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR, BUILDING PERMITS. /-) . c - Scope of Work: r i 'tom 1 /v, l v l7rf 1�ei1- e '2-- Project 2 Project Address: ZI- -7 ff ;V 5 C c✓'/ s 1C c- Project Valuation: w -7P t %(%tr' Contact E-mail OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name. ? '�%l 4 t 0 f ek i G(fi� cc Name: �^ a� `�°\�a, {� C't � Address: Address: 'C% City: G=v <yt,f o State: C City: f t1 dil State: ,A ZIP: ?"4 .' Ph#(IZ-/) f ( ts[t j ZIP: CONTRACTOR INFORMATION Ph#( ) Lic. No: Company Name: Address: City: St: ZIP: DESIGNER INFORMATIONPh#( ) Lic. No: Company Name: Address: City: St: ZIP: LENDING AGENCY Ph#( ) Company Name: i 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: I 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 f �" ^l Date 1 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. F:°Application Forms&Handouts\HANDOUMBuilding Permit Application.docPage 1 of 2 (Revised(07-08-10)