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PR°'� BUIWING PERMIT APPLICATION <br /> a f. 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 <br /> 68-3165THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE-APPLICANT IN ORDER TO APPLY FOR <br /> E BUILDING PERMITS. <br /> Scope of Work: r f u �(c� O���� e% <br /> Project Address: S — W , e SZ Co <br /> Project Valuation: Contact E-mail / Ca <br /> OWNER <br /> NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> -Name: (�.�( tu✓c1C M C1n� 1L Name: {Z C a' <br /> Address-. ZS&zv k/W'/" Z6 Address: .Z<Z <br /> City. � �� StatClty.- nr�?/i State: CA <br /> ZIP: �(p Ph# M/ Ste//-SSS (o ZIP: 95ZEV Ph#R6Ar syy` - alp <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: C ty: St: ZIP: <br /> 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❑ 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 am❑a California licensed contractor or the property owner or❑authorized to act on the-property owner's <br /> behalf(requires written approval and OwnenBuilder Verification Form signed and submitted). <br /> I have read this construction permit application and the information 1 have provided is correct <br /> I agree to comply with all applicable county ordinances and state laws relating.to building constriction. I authorize <br /> representatives of this city or county to enter the above-identified property for inspection purposes_ <br /> Applicant's Signature Date <br /> For your convenience checklists 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 /> FAAppiimflon FDn S&HandouMHANDDUMBuilding Permit Applimfion.docPage 1 of 2 <br />� (Revised(07-OS-50) <br /> k <br />