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11 <br /> °u N <br /> 1q BUILDING PERMIT APPLICATION <br /> 00 - SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> a: s <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: 7777/C 747 a7l,7771 <br /> Project Address: <br /> Project Valuation: j� � S- c Contact E-mail i���r� <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name:Cusp/ `��/t /c/r Name: <br /> Address:,jl/pMICCVS>pt/,,tcj Address: <br /> City: f�,¢ecl State: C/� City: State: <br /> ZIP: 0yS3Dy Ph#(30� /C)f2llo ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No:ffl[le f_� Company Name: �/�/1��j�J <br /> Address:-?3y/dfcl lv—,Ie/-al- City: St:CA ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address:, 731� /�/ /mac /�L/P City: jv St:614ZIP: ys�y <br /> LENDING AGENCY <br /> Company Name: <br /> Address: -✓ City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder" Yes❑ No IJ 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 /> 1 am ❑ a California licensed contractor or he 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 /> have read this construction permit application and the information I have provided is correct. <br /> I agree to comply with all appWable county ordinances and state laws relating to building construction. I authorize <br /> representatives of this ciityd county to enter the abov -,identified property for inspection purposes. <br /> Applicant's Signature / // �U Date J <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 /> FAApplication Forms&Handouts\HANDOUTSOuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />