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BUILDING PERMIT APPLICATION <br /> y f ?a 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 APPLY FOR <br /> BUILDING,PERMITS. <br /> Scope of Work: j,�jC J2vkrvie. {}v <br /> Project Address: k1 -y Ak ,, <br /> Project Valuation: Contact E-mail:y W� svta� u .14 f � <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: � t 7 ouL-Ie\ Ar1Q Name: AT WTD q7I <br /> Address: y -,u, 6 � ye Address: 10o6 F_- Al�WS+ � <br /> City: State: C+ City: UUG t State: <br /> ZIP: IPh#( �f'j 110 g(, ZIP: � � Z �� Ph#(2 ) �8}D Aff z,I <br /> CONTRACTOR INFORMATION Ph#( <br /> Lic. No: � , Company Name: �y( � ( y4*k <br /> Address: rn <br /> - t , ( !L wd City: Lobg StP-- ZIP: f 2 <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 ❑ No ❑ 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 ❑ a California licensed contractor or❑ 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 applicgb�county ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or cquntytto enter the above-identified property for inspection purposes. <br /> Applicant's Si"u <br /> Date J° /7(d?4r/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:\Application Forms&Handouts\HANDOUTS\Building Permit Appiication.docPage 1 of 2 <br /> (Revised(07-08-10) <br />