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ipE <br /> GUILDING PERMIT APPLICATI®N <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: (20) 4683165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING <br /> ITS. <br /> Scope of Work: <br /> Project Address: .7 <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Ic j� �` li Name: '� -ty- E t�l%r ►Z <br /> Address: <br /> � 3 � Address: Sj- <br /> 'l43`( <br /> city: r77pC(�4t>A) State: C;( City: 5 O( L j U/L State: <br /> ZIP: C( Z Ph#(2r7`Q /J065(of0 ZIP: C1 2(� Ph# <br /> (Zo(j) 4f06 Sid o <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#(Ze;l '10(0 tom- ICA c� <br /> Lic. No: (f Company Name: <br /> Address: 47,—f M/i(rV e- � City: <br /> LENDING AGENCY Ph#(-M) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes XJ No 0 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 0 a California licensed contractor or the property owner or 0 authorized to act on the property owner's <br /> behalf(requires written approval and OwneBuilder 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 co my ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or ounty to enter the above-identified property for inspection purposes. <br /> Applicant's Signatur - <br /> {— Date 0 / <br /> For your convenience the kli is detailing ar dditional submittal requirements for various building permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require it types <br /> list. <br /> F:IApplication Forms&HandoutsWANDOUTSIBuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />