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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 /> LtFpR <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: t✓AC 6�, 64 l <br /> Project Address: 17661f 6roC <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: / i e Name: <br /> Address: a�a r'<90 'j-114f&. 6� Address: (� rbyi r� <br /> City: 11Aea c)lj State: IMAI City: (] ��d State: (q <br /> ZIP: Ph#(6S/),�6 ',2®J3 1 ZIP: g303lPh#(9883,93-6YA4 <br /> CONTRACTOR INFORMATION Ph#( 03.6 d-tG ' <br /> Lic. No: Company Name: �'�j D �� !P ICc <br /> Address: lap,,p Wh 6,_On ter r 'f/ I City: ®xna/� St: ZIP: q3®3,,,'4 <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address: City: St: 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 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❑ 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 inspection 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:\Application Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />