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BUILDING PERMIT APPLICATION <br />SAN JOAQUIN COUNTY 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 (WORDER TO APPLY F,OR <br />BUILDING,PERM!TS . <br />Scope of Work:.~ifJq~__t:"AMllLi N ()r'-\\Z. <br />Project Address::;J..hL/~()~, <br />J <br />(]J~""n t£<;(JJ I"N r~fA/!.(\1-.1 i'I N <br />Project Valuation:Contact E-mail:(2.dt)Ii Q f2u ~A.f\)12 {2.c (hzr.'1 A ,t ,(0 ~ <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:~'~I ''£:f2 IP-"l J ~,...1 Name:12.-oQ ~(L.Q?"II U JQ (1'../ <br />,J <br />Address:YI ~I C{.lUNn,:o<,Address:lilo I Cr)(H ..lnl!i.[)S L...J~L~lU lJ \.J) <br />J -" <br />City:I/V1 fl n f?L..T c)State:c tl City:11)1.0 D tr~.,...()State:C JQ <br />ZIP:q <;?,5'I Ph#(20Q)~'41-'2-309 ZIP:9S ~'\1 Ph#(Zt>9)\4 ~23 o C) <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:"St:ZIP: <br />,,~ <br />DESIGNER INFORMATION <br />'d <br />Ph#() <br />Lic.No:Company Name: <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 0 OFF;lyIAL USE ONLY <br />Identification Number: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 />.i.r :,\~',.~ <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT :-~il':"'-;,;i,.1~.r,-, <br />By my signature below,I certify to one of the following: <br />I am 0 a California licensed contractor o~the property owner or 0 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 I :do -?,0 ~I 0 <br />For your convenience ch cklists detailinq any additional submittal requirements for various buildinq permit types <br />are available at the Building Division counter.Demolition permit and mobile home on foundation require check- <br />list. <br />F:\Application Forms &Handouts\HANDOUTS\Building Permit Application,docPage 1 of 2 <br />(Revised (07-08-10)