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°RGurH BUILDING PERMIT APPLICATION <br /> • e r s <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 181.0 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> h ` BUSINESS PHONE: (209)468-3121 <br /> ° 4coaN INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3155- <br /> THE <br /> 68-3165THE APPLICATION MUST BE COMPLETELY FILLED OUT BYTHEAPPLICANT IN ORDER-TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: <br /> Project Address: <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: "M�•' / G Name: A,,Cv/ 407 <br /> Address: Address:/(f ' 2 !nPh# <br /> r �Y <br /> City. �� State: City- e: e4 <br /> ZIP: Ph#(.'O 'G'G —f` ZIP: ^ 2 2 ) 2 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: U Company Name: Z✓C A' <br /> Address: City: eel St:('4 ZIP: 6J2 <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic,No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Narrie: <br /> Address: City: Sb 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 owners <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 El 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 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 inspaction purposes_ <br /> Applicant's Signature Date <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:W,ppiimtion Forms&HandoutsWANDDUTS4Building Pe`mit Appricefion.docPage 1 of t <br /> (Revised(07-08-10) <br />