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BUILDING PERMIT APPLICATION <br /> N Ism j SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> w�(> 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> o" iF6R INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANTIN.ORDER TO APPLY FOR <br /> BUILDING PERMITS-. <br /> Scope of Work: 'Z. N C) J 17 I+ E)4z <br /> Project Address: 8 4ieg o L R-4, ro r 1�{ <br /> Project Valuation: �G27O t 000 Contact E-mail• F vO d i "5 S e "J vna.l • C -,l <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: a Name: QeVk-A $✓.Ick hys 1vtC <br /> Address: 187 Pr s&rq .4vc- Address: 151 V4. ve4 <br /> City: State: CA City: 4._—A rn Ivo State: Ge( <br /> ZIP: 9533b Ph#(201)6gS-loo3 Zip: a[*070 Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lie. No: 45400-7,0 Company Name: Pe( <br /> Address: I*( City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lie. No: Company Name: )-�A <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 ❑ 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❑ 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 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:Wpplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of <br /> (Revised(07-08-10) <br />