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i <br /> BUILDING PERMIT APPLICATION <br /> y � { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> °4C1k'o'Rt`° 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:�FIVSIAGL A,5 SECGw,O PW0A1W1Ve pit, Z&AI <br /> Project Address: A ( 74? �, r6ll Or 4'0- ACAIS!� CA . 9 S�otQ <br /> Project Valuation: / 0.4 000 Contact E-mail:OR7'rCAIX11C 1AXISOMM0047 <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name:. 1A C,Z62 Name: OCIN KI-Ace <br /> Address:.2A/q gq Al, f6lAoe ILD Address: 610f S. S70C/C7'(1/1 Sr <br /> City: A CAM l°O State: CA. City: 1,elq- State: CA <br /> ZIP: g5o2a U Ph#Lf10) /q/S-o2 ygU I ZIP: ,-02 D <br /> CONTRACTORINFORMATION Ph#pe q) 333 - r//gyp <br /> Lic. No: 66,3YSO I Company Name: D fZ %CC`//I//G /AWS <br /> Address:,5"0S. S7U6/LT(//V Sr City: L ov,�r St4`4 ZIP:q,3-,2 /f6 <br /> DESIGNER INFORMATION Ph#( ) <br /> o: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> ompany ame: A Cj <br /> Address:,26; [SW CI0,11- A(16 19M City: Al SACksiMuvTm St:GA, ZIP: 9j 6 <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 amA,a California licensed contractor or E] the property owner or E] 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 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 �CY / Date OC-7 0q <br /> O9-a/y <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 /> FAApplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />