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BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> Ni1 . . 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> ' BUSINESS PHONE: (209) 468-3121 <br /> 09"""•`" INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> cr�o� <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY <br /> .FOR <br /> BUILDING PERMITS, <br /> Scope of Work: ^ <br /> Project Address: e';p <br /> Project Valuation: 4Q — Contact E-mail. <br /> OWNER NAME AND ADDRESS AP LIC NT NAME AND AD RES <br /> Name: Name: r <br /> Addre 4 Address: <br /> City: Sta e: City: XP State: <br /> ZIP: 6 Ph#( ) j s ZIP: Ph#( ) G a <br /> CONTRACTOR INFORMATION Ph#(gyp ) <br /> Lie. No: Company Name: <br /> Address: City: St ZIP: 6 <br /> DESIGNER INFORMATION Ph#( 0j) 9Y. <br /> Lic. No: Company Name:kv A" <br /> Address: b City: St: ZIP: <br /> LENDING AGE CY 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 /> I ama California licensed contractor or E] the property owner or ❑ authorized to act on the property owner's <br /> beha f (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 Lomply-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 tee' ' 11te61AALM�(k A Date r9y o��j /rip/r7' <br /> For your convenience chec sts 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 /> FAApplication Forms&HandoutMANDOUMBuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />