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o� �o BUILDING PERMIT APPLICATION <br /> y ,,.• < <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E,HAZELTONAVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> d j p t+� � „ )•t 0 e INSPECTION REQUEST-24 HOUR RECORDER;4209)468.3165 <br /> THE Ap(?LIGATION MUST BE C'OMPLETFLY FILLEgOUT•BY,Tt{E APPLICANT IN ORDER TO APEsLY FOR. .: <br /> -' ` •.BUILf�1NG PERMITSr-:.`: ? `' " ' ' <br /> Scope of Work: c '1 \10 VCIJ ' SLI 5 �-� t ' �( <br /> Project Address: <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME gNI)'ADDRESS. APPLICANT NAM K AND ADPq $S <br /> Name: - 0L d{1 ez Name: QWIA e <br /> Address:',1300A <br /> t 0 , PZ(r�� Address: . <br /> C)ty: g . State: City: State: <br /> ZIP: Ph#( - (a¢ ZIP: P 14( ) <br /> CONTRACTOR'INPORMATION Ph#( ) <br /> Lie. No: Company_Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION; Ph#( ) <br /> Lic, No: Company Name: <br /> Address: City; St: <br /> ZIP: <br /> LENbING AGENCYi. Ph#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be Issued loan"Owner-Builder' Yes "No F-1 OFFICIAL USS,POLY,If yes, a completed Owner-Builder Verification Form must Identi0cation Number: <br /> be signed and submitted along with copy of the owners <br /> Identification prior to issuance of the building permit.. - <br /> DECtARQ1(ON DY;OONSTRI�CTION PERMIT APPLICANT <br /> By my signature below, i certify to one of the )[owing: <br /> I am [] a California licensed eonfractor or f e property owner orEl authorized.to not on the property owner's <br /> behalf(requires written approval and Ow er under 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. [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 formarlous building permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require chock- <br /> list. <br /> F:Application Forms&HendoulMANPOUTSIBuilding Permit Appllcellon.docPage 1 of 2 <br /> (Revised(07-08-10) <br />