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e'�E9 �P:1At!I.iVid COUNT <br /> COMIMI.II'I " DEVELOPMEHT DEf"AR T MEN 9 <br /> 'I810 E. I-I/1ZELTQN AVENUE,al'OCKTO119 CA 95205 <br /> BUSINESS (SHONE: (209)468-311211 <br /> INSPECTION RECIUES I-24 HOUR R.F:C ORDF7R: (209)468-8'165 <br /> ��FOR <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDLR�i®APF°I_Y FOR <br /> BUILUINO PERMITS. <br /> Scope of worl<: <br /> ' Project Address: f 'T f3 Z y) <br /> Project Valuation: /zy° Contact E-mail:f fQ/ 4 = , <br /> , , y <br /> ' OWNER NAME ANIS AC URL-88 APPLICANT N'A'ME AND ADDRESS <br /> Name: W611 emch Name: 10(415Al-IJ rr _ <br /> Address: fLv Address: I pp7Q AI <br /> City: y> State: ' City:L State: <br /> ZIP: Cj 3�, Ph#(? ;"l ZIP: ,r-Z Ph#('? <br /> tCONTRACTOR INFORMI-ni ON Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION N Ph#( ) <br /> ' Lic. No: Co 24&1-1 ConpannyName: bc 6e- <br /> CityAddress: 2,Zq/ W•Mo_eC Zee.,Jc8>JC : St:r� ZIP: <br /> LENDING AGENCY h#( <br /> ) <br /> Company Name: <br /> ' Address: City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder" YesNo❑ OFFICIAL USE ONLY <br /> If yes, a completed Owner-Builder Verification F rm 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 am ❑ a California licensed contractor mr the Property owner or.1n'authori-ed to act on the property owner's <br /> ' behalf(requires written approval and Ovundr/Bitilder Verification Farm 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 aN applicable county ordinances and state laws relating to building construction. I authorize <br /> representatives of thi ci/t�,or county to�pter the.. <br /> bbove-id/pntified property for inspection purposes. <br /> �, �' Applicant's Signa i Date <br /> _ <br /> For your convenience checklists detailing any additional submittal requirements for va is us buil ing 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&HandoutsiHANDOU FMBuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />