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(5-4, <br /> )Z, <br /> BUILDING PERMIT APPLICATIONSAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLEDOUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: L'IVCto99 CaNO ft 7' „2(q 'A!U <br /> Project Address: //ZS_ 7 A/, /� 0S Xe, . G pQ/ 11 c,41 95- e <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: /r3� /L! ��� /�{C 3!o!r/ Name: 11?61?a /TCY10,0 <br /> Address: !/7.S- t/ �O/�o S 124 Address: 1''7S-7 /•(/, 0*0/ 9 C4, <br /> City: GdQ State: � City: GOJ// State: <br /> ZIP: q Z Ph#( )36 _3aZIP: <br /> Sr Z Pn#(Zp 367 36d'3 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lie. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lie. 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 QY CONSTRUCTION PERMIT'APPLICANT <br /> By my signature below, I certify to one of the following: <br /> I am ❑a California licensed contractor or,K the property owner or❑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,[,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 3 <br /> Dale <br /> For your convenienc check[! detailing any additional submittal requirements 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 /> ':1Application Fonns&HandoutsXHANDOUTSOullding Permit Appllcatlon.docPage 1 of 2 <br /> Revised(07-08-10) <br />