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BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209)468-3121 q< FonN`4 INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: (Ie�. Project Address:Address: 0 b q et L. c,'c� ( Ce� t'3 C)q Project Valuation: Contact E-mail: OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: �• Name: Address: ( o q irk Address: City: rrA State: C Q City: State: ZIP: 9 r � Ph#(Sio ) 2,4r. ..k. . al I ZIP: Ph#( ) CONTRACTOR INFORMATION Ph#( ) Lia No: Company Name: Address: 07 ✓a ✓2y S•7 City: Ga St:CaZIP: FS 360 DESIGNER INFORMATION Ph#( ) Lic, No: Company Name: Address: City: St: ZIP: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder' Yes ❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owners identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to one of the following: I am ❑ a California licensed contractor or❑ the property owner or❑authorized to act on the property owner's behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the information I have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction, I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Applicant's Signature r��^ �yL / Date /! / 2a 3 For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. F:VAppliration Fonns&HandoutMHANDOUTMuilding Permit Application.docPage 1 oft (Revised(07-08-10)