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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 :rHE APPLICANT IN ORDER TO APPLY FOR <br />BUILDING PERMITS. <br />Scope of Work:'b£:M0 /oi fN 81+RJJ <br />Project Address:4-001 MfJ1<PfJRGfJ4 tx:z &:7<N CA q5;;-/~ <br />Project Valuation:Contact E-mail: <br />-., <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:~ML4 Lj,13f<vt9CJL Name:S(.}M£ <br />Address:L/OtJ1 1t1A-(2.i-1t f.2..bO A !:X<_I Address: <br />City:Sfl)Clc:WN..State:C4-City:State: <br />ZIP:q5~j5 Ph#()ZIP:Ph#() <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St:ZIP: <br />"DESIGNER INFORMATION .-'~i 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 IXf No 0 '"'c_-,l"<".'"OFFfcIAt::iUSE"QNLY ,0 <br />.-.,'-<e-, <br />If yes,a completed Owner-Builder Verification Form must Identification Number: <br />be signed and submitted along with copy of the owner's kOlfJ75 f/identification prior to issuance of the building permit. <br />I 'f.. <br />DECLA~TION BY CONS~R~CTION ~E~~ITe-PPL.'s6~~j:ilif.4t~1r1'~~~~J:,'/ <br />By my signature below,I certify to one of the following: <br />I am 0 a California licensed contractor oriZT 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 euu UI foJ)J$Date '-/-/3 ~/! <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:lApplication Forms &Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)