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BUILDING PERMIT APPLICATION <br /> v• '?., 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: AUft Y CXAJO�J,14421 <br /> �t <br /> Project Address: JJVdtZ G1.� <br /> Project Valuation: 167® Ovp Contact E-mail: 6e41,y, %1 g,r 4S1 a <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: LD Name: w t ~ <br /> Address: (t Z, Address: Ito (31ts <br /> City: �D� State: City: State: C.4 <br /> ZIP: '11r) (Q Ph#( (013 ' �05�� ZIP: ft3 Ph#( ) f I f <br /> CONTRACTOR INFORMATION Ph#(go ) <br /> Lic. No: y O Company Name: Lrst-PSIs• <br /> Address: iisr p 'p,A, d>tdA. AVe, City: P' 0061tro St: ZIP: q <br /> DESIGNER INFORMATION Ph#(%A) 4011 -$J 03 <br /> Lic. No: Company Name: (4t",toz. p1„4,31 <br /> Address: q`$ (b 3 City: St: C.a, ZIP153rj <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder" Yes ❑ No Re 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 applicable county ordinances and state laws relating to building construction. I authorize <br /> representatives of this city o y to enter the above-identified property for inspection purposes. <br /> i <br /> Applicant'sSignare Date D3 'Z7' �.� <br /> For your convenien cklists detailing any additional submittal requirements for various building permit types <br /> are available at the uilding Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:Wpplication Forms&HandoutsXHANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />