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BUILDING PERMIT APPLICATION <br /> a' ? 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 MUSTBE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: N�M O 1�ZfZs,,"t i W(v,-g1Lr <br /> Project Address: 6,5&3 t S_OP,- FG,J exp <br /> Project Valuation: Contact E-mail• <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: O <br /> .a.J �L, Name: 6 Address: 04b b Address: A51 (..IE4iI,4o-54 blL <br /> City: State: e�,� City: 51741 State: C4` <br /> ZIP: efy/-5- Ph#( ) /02- ZIP: 9 Ph#(Zfl6t,7/2I Z <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic.No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION I' 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 ONo❑ 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�pq{authorized to act on the property owner's' <br /> behalf(requires written approval and Owner/Builder Verification Fotlrt§lgned and submitted). <br /> I have read this construction permit application and the information I have provided is correct. <br /> 1 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 />' RXApplicalion Fonns&Handouts\HANDOUMBuilding Permit Application.docPage 1 of 2 <br /> (Revised:(07-08-10) <br /> I <br />