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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 />Scope of Work: <br />Project Address: <br />Project Valuation: <br />0WN6R NAME AND ADDRESS <br />ct L 'S~ <br />Address:tl~~ST R-J <br />City:~"'-'~Wl State: <br />ZIP:qS--~7:> <br />Contact E-mail: <br />City:State:~. <br />Ph#(Icff)t1DI-&'1ZIP: <br />Company Name:L\vi ~ <br />CONTRACTOR INFORMATION Ph#( <br />City: <br />DESIGNER INFORMATION Ph#( <br />Lic.No:Company Name: <br />Address: <br />LENDING AGENCY <br />Company Name: <br />st:.ZIP: <br />Address: <br />City: <br />Ph#( <br />City:si.ZIP: <br />I am ~a California licensed contractor or 0 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 />Permit will be issued to an "Owner-Builder"Yes 0 No 0 <br />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 />Identification Number: <br />I have read this construction permit app].n and the information I have prov.ided is correct. <br />I agree to comply with all applicable untyor inances and state laws relating to building construction.I authorize <br />representatives of this or co nt 0 ent e above-identified property for inspection purposes. <br />Applicant's Signature-=~'¥-~7P"==--i--~~~,.,c:!.~",=~""",--Date JJ--.;;m.lO <br />For your convenience cklists detailing any additional submittal requirements for various building permit types <br />are available at the Bu I ing Division counter.Demolition permit and mobile home on foundation require check- <br />list. <br />F:\Applicalion Forms &Handouls\HANDOUTS\8uilding Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)