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ip <br /> BUILDING PERMIT �4PPLICATION <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: ProcmAto 01 c-e- t It <br /> Project Address 66PI lw_b�, R a� <br /> Project Valuation: lqw O Contact E-mail:Gvrctov, �o}e C-0c Cop) <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: �te� { Name: Q ` 1 ,Ucl� mtxa t <br /> Address: 0 Qxt Address: 53 sic,,1�. e <br /> City:ss N e le- q State: State: C,,, <br /> ZIP: 9 LIsIPh#( ) ZIP: Ph#Rtjj)53.3- 1119 t <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: )1070 I Company Name: rbc-k. ti 1,.)wg ®Dwr^t Corp <br /> Address: 1321 ity 'ii St: ZIP:jSLIL-)-3 <br /> DESIGNER INFORMATION I Ph#(Z(n) s 17— }4$ <br /> Lic. No: 317 H g Company Name: O cz <br /> Address: `1 a`$ st S} ICity: �jp St:c� ZIP:95n <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 Siigggature below, I certify to one of the following: <br /> I am IJY 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 1 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 ent r the above-identified property for inspection purposes. <br /> Applicant's Signature 1n Date 10'-11- 13 <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 /> FAppllcation Forms&HandouWHANDOUMBuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />