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��1FORC7• <br />BUILDING PERMIT APPLICATION <br />SAN JOAQUIN COUNT( COMMUNITY DEVELOPMENT DEPARTMENT <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 ORD.ER-TO APPLY FOR <br />BUILDING PERMITS. <br />Scope of Work: 09 V <br />Project Address: �� r � C <br />Project Valuation: <br />Contact E-mail: ? <br />OWNER NAME AND ADDRESS <br />APPLICANT NAME AND ADDRESS <br />Name:— <br />Name: -- <br />Address: _ <br />_dress: S �– <br />City: <br />State: <br />City: <br />State: <br />ZIP: <br />Ph#(7 _9,1Z1 <br />ZIP: <br />Ph# <br />CONTRACTOR INFORMATION <br />Ph#( } <br />Lic. No: <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />DESIGNER INFORMATION <br />Ph#( ) <br />Lic. No: <br />Company Name: <br />Address: <br />City:St: <br />ZIP: <br />LENDING AGENCY <br />Ph#( } <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />Permit will be issued to an "Owner -Builder" Yes ❑ No ❑ <br />If yes, a completed Owner -Builder Verification Form must <br />be signed and submitted along with copy of the owner's <br />identification prior to issuance of the building permit. <br />OFFICIAL USE ONLY <br />Identification Number <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 OwnerlBuilder Verificatio►i 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 lawsrelating.to building construction I authorize <br />representatives of this city or county to enter the above -identified property for inspection purposes_ <br />Applicant's Signature4z" , Date M <br />77 <br />For your convenience checklists detailing any ad' iona submittal requirements for various building permit types <br />are available at the Building Division counter. D olition permit and mobile home on foundation require check- <br />list. <br />F:\Appliration Forms & Handouts\HANDOUTMuilding Permit Appllcation,docPage 1 of 2 <br />(Revised (07-M10) <br />