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�p4U`" -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 /> °4 jFORi;`" 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: V n <br /> Project Address: LI I ) O S- -4 T_ <br /> 1 <br /> Project Valuation: -0 Sop pct a= ContactE-mail: 'LC 5 50 C a I-a X10(fit 6i S <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS CLI Co <br /> Name: r C, Savii f5 Name: <br /> Address: j&5+T/' Address: <br /> City: State: (✓ City: State: <br /> ZIP: 53 D Ph# ) qlq . 5000 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: 0 y X&tAA S 5 o (!,z �3 <br /> Address: �� �'� � ( City: I w&e < -f-cD St:c,(+ ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: o - <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes?j No F-1 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 R 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 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 ente the above-identified property for inspection purposes. <br /> Applicant's SignatureDate <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:Wpplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />