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BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468-3121 INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: Living Project Address: J S � OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: k 5 > l 3 t CSCR 1` w� Name: OI D rc0,1n0 Address: '1 1 9- a_rmar\ Address: 2( Z r t-\C I A "- City: S-4 C - State: CA City: D ck�01--\ State: C/9 ZIP: 5 ZJ Ph#(IDQ) Ll 9& -/?3 ZIP: r_> Ph#(`fid IBO(?) y� CONTRACTOR INFORMATION Ph#( ) Lic. No: Company Name: Address: City: St: ZIP: DESIGNER INFORMATION Ph#( ) Lic. No: Company Name: Address: 2,12- P A V�V_,, I City: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder' Yes ❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to one of the following: I am ❑ a California licensed contractor or❑ the property owner or ❑ authorized to act on the property owner's behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the information I have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Applicant's Signatu19 �3e.VtO"t^0 Date—6//L7 2-0/3 For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. F:IBUILDINMHANDOUTS\Building Permit Applicalion.doc Page 1 of 2 (Revised 1-23-09)