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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 IN ORDER TO APPL Y FOR <br />BUILDING PERMITS. <br />Scope of Work:K e -(2)L)vJ o '\-o:)+-Iov-;-e <br />Project Address:Crt 2.2-M c k.e 'V\.\~_.11 OI..\).iL <br />OWNER NAME AND ADDRESS J APPLICANT NAME AND ADDRESS <br />Name:~\}\U e.i'Y\a.vJ.<2.?-Name:n('~vJn tv(e,1\\rO.- <br />Address:10 to 5"1 f.A~{).(A v e:Address:S-s 5 "3 .f llJa~L ~LV'-- <br />City~_l ::x.*:--\-e>~State:CA.CitY~ck~State:C~· <br />ZIP:CfS-Z,S-Ph#Q.O~)(pL.t ~-o~S-C\ZIP:q S"11 ':)Ph#("2..tc\)Y:tD ·qO?p) <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name: <br />Address:City:St:ZIP: <br />DESIGNER INFORMATION 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 D No D OFFICIAL USE ONL Y <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 D a California licensed contractor or 0 the property owner or ~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 countyAordina ces and state laws relating to building construction.I authorize <br />representatives of .n:to ent re a 'Fe-identified property tor inspection purposes. <br />Applicant's Signatur -;::T"C./V 1h \f---/Date ~-5 -'2-0lD <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:\8UILDING\HANDOUTS\8uilding Permit AppJication.doc <br />(Revised 1-23-09) <br />Page 1 of2