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BUILDING PERMIT APPLICATION <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br />BUSINESS PHONE: (209) 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: <br />Project Address: t' a ✓�i� �� <br />Project Valuation: /,6 06)0 <br />Contact E-mail: C G) -t r t <br />OWNER NAME.AND ADDRESS <br />-APPLICANT NAME AND ADDRESS <br />Name:. 1(1)1/711 <br />Name: 1 1/7111 � 5d1-1, I )-" �~I� 1 �'. <br />Address: %� rJGr� J�' <br />Address: <br />City: 1 �� <br />State: C�ir� <br />City: <br />State; CA <br />'LIP: ' 2 <br />Ph#( } <br />ZIP: G) 2 <br />Ph#( 61 GJ�P <br />CONTRACTOR INFORMATION..' ;: <br />Ph#( ) <br />Lic. No: <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />DESIGNER INFORMATION <br />Ph#(z� q�Zq /,SIS k <br />L.ic. No: <br />-» ^ <br />Company Name: ' h cv:�5 -, rof fa y_d <br />Address: ' <br />City: -51?--) t <br />St: <br />LENDING AGENCY <br />Ph#( } <br />Company Name: <br />Address: <br />City: _ <br />TSt: ZIP: <br />Permit will be issued to an "Owner -Builder" Yes ❑ No ❑ <br />If yes, a completed Owner -Builder Verification Form must <br />be signed and submitted along with copy of the owner's <br />identification prior to issuanco of the building permit. <br />OFFICIA1_.USE ONLY `:.:.: <br />Identification Number: <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br />By my signature below, I certify to one of the following: <br />I am Cj a California licensed contractor or ❑ the property owner or �<authorixed 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 cit r county to ente, the above -identified property for inspection purposes. <br />Applicant's Signature �' Dato.—_/-( <br />For your convenien he lists detailingany ditio I submittal requirements for various building permit types <br />are available at the Building Division counter. e�moliti n permit and mobile home on foundation require check- <br />list. <br />FA\Application Farms & Handouts\HANDQUTS\Building Permit Application.docPage i of 2 <br />(Revisod (07-08-10) <br />