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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:(()AS\-~V'\)..lJ).t~~jJ <br />Project Address:L(0 l (\(Z lS-t 1-1tLAvl t+Y <br />Project Valuation:'f=-I.<0 0 o Contact E-mail: <br />OWNER NAME A~D ADDRESS APPLICANT NAME AND ADDRESS <br />Name:!;(-f./:.-.,J l~tI?~,(O+CLJ+-z Name: <br />Address:110 It TIrL ~vJ"y Address: <br />City:LoJ,State:(V~.City:State: <br />ZIP:C]S2JI D Ph#Qo;)~\o 3-ObS D ZIP:Ph#() <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:roo b'110 «Company Name:L ~~Cd f).~5frvL1 /1)" <br />Address:P.0 \~y «-2fo City:L 0)"st:ZIP:~)'2.1I <br />DESIGNER INFORMATION Ph#(/(J ,7/Z--/fZ2- <br />Lic.NO:~5~£>~)Company Name:L ('5."')'a:f\f1 ,'",')5 <br />Address:VI 0,~h x:L.[o1 City:1.-0)1'St:ZIP:e1f?<t ( <br />LENDING AGENCY Ph#() <br />Company Name: <br />Address:City:st:ZIP: <br />Permit wi"be issued to an "Owner-Builder"Yes D No D 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 mzre below,I certify to one of the following: <br />I am a California 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 provided is correct. <br />I agree to comply with all app~ty ordinances nd state laws relating to building construction.I authorize <br />representatives of this city or count enter the abo -identifie property for inspection purposes. <br />Applicant's Signature --6'pc;to ';j~Date 3-~-(( <br />For your convenience Ch"sts detail~g 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 />F:\Application Forms &Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)