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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 />LENDING AGENCY <br />City:St:ZIP: <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 r.'i .1,1-1 •..,...:A-t.. <br />CONTRACTOR INFORMATION <br />APPLICANT NAME AND ADDRESS <br />Project Valuation:Contact E-mail: <br />OWNER NAME AND ADDRESS <br />Name:1/_/-C'.e ;'~l.JS ':~---~"--.J.-_., <br />Address:\A .•JJ)~_.J <br />City:,)/":)..State:•J <br />'\...!/-I <br />ZIP:l ''(..Ph#())."")'/I <br />Name: <br />-Address:.J I':} <br />City:All./N,J/C State:{tIt <br />Ph#( <br />Lic.No:~.-Company Name: <br />DESIGNER INFORMATION <br />City:/l16 ac S 7r St:(1/./ZIP:Q~~~IAddress:r (I ~i I ~I f I (r <br />Ph#() <br />Lic.No:Company Name: <br />Address: <br />Ph#( <br />Company Name: <br />Address: <br />OFFICIAL USE ONLY <br />City:St:ZIP: <br />Permit will be issued to an "Owner-Builder"Yes 0 No bJ. <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 issuance of the building permit. <br />Identification Number: <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br />By my signature below,I certify to one of the following: <br />I am 0 a California licensed contractor or 0 the property owner or 0 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 cit unty to enter t~above-identified property for inspection purposes. <br />/'L ~/7~/7 /'//-Date_....;.;_~_/<-,::--_ <br />; <br />For your convenience c ecklists 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 />Applicant's Signature <br />F:\Applicalion Forms &Handouls\HANDOUTS\Suilding Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)