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°q....vity �o BUILDING PERMIT APPLICATION <br /> ti <br /> a \ 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: ' eUe A-p 0 1T-1 vN <br /> Project Address: ([ 2CPej q-}W6e?,TMr..) CA <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: pH-Atau01) rl cupjme Name: N�- <br /> Address: 1(e&. r(} }p(4 fyCV ) A -:-) Address: <br /> City: 7n/j State: GA City: State: <br /> ZIP: S Ph#( ) ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: Cwt I fV--f-/6Cj 1 U42 ON's <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( <br /> Lic. No: G X75 Company Name: , .nria A � <br /> Address:1 6ZAS �( fpr] c� City: St: C 'f 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 /> am ❑ a California licensed contractor or❑the property owner or❑ authorized to act on the property owner's <br /> behalf(requires written approval and OwneABuilder 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 th"bove-identified property for inspection purposes. <br /> Applicant's Signature X—�>61eeli!316� 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 /> FABUILDING\HANDOUTS\Building Permit Application.doc Page 1 of 2 <br /> (Revised 1-23-09) <br />