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� € BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> k 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: 209 <br /> � ;.� ( ) 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: r � <br /> Project Address: <br /> Project Valuation: ��� n <br /> � Contact E-mail: GZ.rGt'1 r�yy( � <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ��a,),.tEA �le�E� Name: NgeM/'�N k�IL= N <br /> Address: Icp' S orvi iLLis RD Address: (off ��- <br /> City: 6JMK1Dt1I I State: CA City: 7`'[�� State: CA <br /> ZIP: CIS 2I r-J IPh#(�rJ)4(02jcfg j ZIP: � _3 Ph#( ZI S77" oll <br /> CONTRACTOR INFORMATION Ph#( ) 6(11-j-&158 <br /> Lic. No: 170Company Name: <br /> Address: I� �� ° -- <br /> 7 ,1 r p h , t' U, fZD I City: �--e�LDr.1 st:c- ZIP: <br /> DESIGNER INFORMATION Ph#( ) '1�.� — 74 <br /> Lia No: G 15� Company Name: 1�IL�b1J (TFs?i� <br /> Address: (Duel LATH dbT City: MppZIP: 5 <br /> LENDING AGENCY Ph#( " 5-77 17 114 <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes ❑ No OFFICIAL USE ONLY 0iIf 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 am ❑ a California licensed contractor or[-I 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 I have provided is correct. <br /> I agree tocomply with all applicabl 0 c y ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or cou y enter t e above-identified property for inspection purposes. <br /> Applicant's Signature % Date / L24 �3 p <br /> r' <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 /> F:Mpplication Forms&Handoots\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />