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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 />THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br />BUILDING PERMITS. <br />Scope of Work:ijJ'J{tI f)J~10 IlAwl }th~11 t1J..flt /I .c»ftIvt/o)/J ..dA Jh~/Jl1/rlI/Y)1P <br />Project Address:I L/q IJ 0 11)'-1r1IJJ.;U /J....Contact E-mail:11M"I \e.r I/V\I)J I e ~(Q /J it.V'l e:1- <br />OWNER NAME AND ADmt{ESS APPLICANT NAME AND ADDRESS <br />Name:n~'1/,diHM Name:O{Jf\/,\I'<;\.LLlI~e..r& <br />IAJ.IZe.t+\~~V\ <br />...J <br />-Ji=.:=5 C;/JAddress:IOY 0 ~-~~{)Address:}01./Ii LJ.If e.H-I ~AV\ <br />City:l roff State:L ~'\City:Lod'State:ct4 <br />ZIP:i1 t:;.1 q o Ph#(j 0'1)t1 <:..(J 0'5 t/ZIP:D,'j,J....'-//J Ph#(jtA)0/6'('-/';/JC4 <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St:ZIP: <br />~u.~~~ecr--DESIGNER INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St:ZIP: <br />LENDING AGENCY Ph#() <br />Company Name: <br />Address:City:St:ZIP: <br />Permit will be issued to an "Owner-Builder"Yes 0 No 0 OFFICIAL USE ONL Y <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 am 0 a California licensed contractor or 0 the property owner or 5(jauthorized 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 ~--:f}CI.AA t)(]./Date 3 -I~..J,IJI 0 <br />For your convenience checkli-;t's detailil;;g an~=submittal requirements for various building permit types <br />are available at the Building Division counter.21 molition permit and mobile home on foundation require check- <br />list. <br />F:\BUILDING\HANDOUTS\8uilding Permit Application.doc <br />(Revised (07-22-09) <br />Page 1 of2