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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 APPLY FOR <br />BUILDING PERMITS. <br />Scope of Wone <br />Project Address: <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:,\...\\N\e "'0 ~~~\\"'lA Name:-,h\/\1\.e .c:...,~'v,-E\\0--. <br />Address:~Q(/r:VV\u V\(>~~~A V -e'Address:~9 .c ~LA..V\\<.<~A\.1~ <br />City:"S\.rl('<-~o ,____State:C c-.City::)-\cx'<--\()--.State:(c- <br />ZIP:Cf Szt <S Ph#(ZO")5/~276 L ZIP:9 ~2 \S Ph#(z09)512>Z (b'C <br />CONTRACTOR INFORMATION Ph#() <br />lie.No:Company Name: <br />Address:City:St:ZIP: <br />DESIGNER INFORMATION Ph#() <br />lie.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 0 a California licensed contractor or li&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 />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-id ntified property for inspection purposes., <br />Applicanfs Signature /C/JUvc..-glt 'Date /-/6 -0 S~ <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 Application.doc <br />(Revised1-2~) <br />Page 1 of 2