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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 :rHE APP~ICANT IN ORDER TO'APPLY F.OR <br />BUILDING"PERMITS.,,- <br />Scope of Work:Oe","",o I,·..•.i OM.. <br />Project Address:/1,,;Z.!r /.s.T?-c.c~IT /vd 5 +0 c.Jc.+o h C c.. <br />I / <br />Contact E-mail:De (Ie-0 (.f J (J .£to l.Project Valuation:I I,cQ e>.~c:>·Co~ <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:ec D~~~""'-:r-()Gc C V '""-Name:GoD ll-,...rJ ,.If,.((d SU'V <br />Address:~Address:p.<9.(30)(t c 7J4'1 N..s~:r o c e c ;...,U. <br />City:S~e~t-.-'\..State:c.;City:<-<Joo d.(.:«State:C c.. <br />ZIP:7 <5-2 0 :2-Ph#(:z.0'1)'r'''R,-"3'('{(ZIP:'i S--17 "Ph#(530)C c».;z d «J <br />CONTRACTOR INFORMATION Ph#(5]0)c c :r :;Z....a 'f / <br />Lic.No:s «/),7 ~?Company Name:a-r-:<9:rf,'c../1 s:». <br />Address:p.O.fSo'JC 1[7.r City:WOe!d t.:«sr c :ZIP:cr S'?7 ( <br />.~ <br />DESIGNER INFORMATION Ph#() <br />Lic.No:Company Name:IV-14 <br />Address:City:St:ZIP:. <br />LENDING AGENCY Ph#() <br />Company Name:Yl/-14 <br />Address:City:st:ZIP: <br />Permit will be issued to an "Owner-Builder"Yes D No D OFSI.cIA~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 />"-DECLA~~TION B/CQNSTRUCTION PERMIT APPLlCA~+.,.'~"':l~~T".,.:~,;~•.•._.!!;.:;:r;d'~:;J .:~?f-~r~. <br />By my signature below,I certify to one of the following: <br />I am ~alifornia licensed contractor or D the property owner or D authorized 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 prov.ided 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 Signalure d -~U (O~/.f"(9:(.J';t I j )Date 1-Ii -l 0 <br />For your conveniee~hecklists detailing any additi~al submittal reqUiren/ents for various building permit types <br />are available at the uilding Division counter.Demolition permit and mobile home on foundation require check- <br />list. <br />F:\Application Forms &Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br />(Revised (07·08-10)