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BUILDING PERMIT APPLICATION <br /> J ?� SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> �94jpd'(t��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: <br /> 2A,lf' FjQANce, p i <br /> Project Address: c( W O � r ' L\' Amt 3, <br /> Project Valuation: Contact E-mail: �gOraogt �n e� yrtgt� ,eoM <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ��CSR�t T i Name: Ir Ol U f'01 f) R <br /> Address: X"Pen lerlr Address: ��,9 Pa 0 M <br /> City: Q� Q State: �G City: � � pn State: <br /> ZIP: Ph#( �x�3 386 ZIP: gSz(D Ph#(-Zz Gt0 .-10'30 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#(iag ) Fo 10 <br /> Lic. No: Company Name: \L_qvq-CLS L? <br /> Address: r q6q 'pM oyvl a Awe � j, C) I st:ck) . ZIP: (IS7,C9 <br /> LENDING AGENCYPh#( ) <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 Date <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 Application.docPage 1 of 2 <br /> (Revised(07-08-10) - <br />