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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 /> iFBF< P 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: A{ t --rP_A C <br /> JL <br /> Project Address: Z`i 8l S "6UNJra r10USF Pb 1,s,`C <br /> Project Valuation: (Op Jc Contact E-mail: L S EO U Lt a-A Q 1-(1^1 14, COlst1 <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ?(v Name: LAftS Sfaotla& <br /> Address: 2`(C7 t, 5 r1ovn/ r r 11 1°AV 4.t Address: _ lg 1 US I N£ yS W by S°r rf I 0 1 <br /> City: Te State: CA City: SAC R ppkry r State: CA <br /> ZIP: Ph#( ) ZIP: Ph#(qi b ) 3 gg <br /> CONTRACTOR INFORMATION Ph#(9(6 ) 3a} �-iflLS <br /> Lic. No: -:Z0 C[ Company Name: H PNA 13U L L bf(Z <br /> Address: IS golti�S5 PPt c- \,JA`{ 10j City: SACM4 ro-d St: (A ZIP: Q$�Z� <br /> DESIGNER INFORMATION Ph#(y I S)H-] <br /> Lic. No: C 1 % I 1 lo2 I Company Name: PG j_ <br /> Address: AV .'c S t Q Va Y L416 City: SAN coSt:(14- ZIP: 11(7 <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 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 �f) 9 6_ Date V741 Z <br /> For your convenient fists detatlfrfg any additional submittal requirements for various building permit types <br /> are available at thDivision counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:VApplication Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />