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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 />THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br />BUILDING PERMITS. <br />Scope of Work:\r15171 U 1111 ~7)f Iln4($Pl,MH 1)U;L/~aA <br />Project Address:'W(06 0.~/.J'9 /..'''Y I 12d.I <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:l+o.YD ld JtU111?S Name:Valley Permit Services-fnQ~"", <br />Address:'7;::;Jo t»5.1u-1L4\V1 rU.Address:Discovery Bay,CA 94505?nQ_""..,•••,,""•• <br />City:-rvzt~State:CA .'-'V"City:State: <br />ZIP:ClCJ?o4 Ph#(2tfP ~r S:-lP t to I ZIP:Ph#() <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St ZIP: <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 0 OFFICIAL USE ONL Y <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 CONS1RUCTION 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 ~authorized to act on the property owner's <br />.behalf (requires written approval and OwnerlBuilder 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:\BUILDING\HANDOUTS\Building Pennit Application.doc <br />(Revised 1-23-09) <br />Page 1 of2