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=SAN PERMIT APPLICATION <br /> o. <br /> —4 •yCOMMUNITY DEVELOPMENT DEPARTMENHAZELTON AVENUE, STOCKTON CA 95205BUSINESS PHONE: (209)468-3121 <br /> UEST-24 HOUR RECORDER: (209) 468-3165 <br /> 'r�fFOF}N <br /> THE APPLICATION MUST BE COMPLETE BUILDING PERMITS. E APPLICANT IN ORDER O APPLY FOR <br /> T <br /> ) <br /> Scope of Work: <br /> Project Address: lC <br /> Contact E-mail: <br /> Project Valuation: <br /> APPLICANT NAME AND ADDRESS <br /> OWNER NAME AND ADDRESS <br /> y Name: <br /> v3 c v <br /> Name: 6 CC <br /> pp Address: <br /> Address C3 . 17C� yL � State: <br /> City: �7TCC <br /> City: SLUG-QTc i State: <br /> ZIP: 2 P11#( ) <br /> CONTRACTOR INFORMATION <br /> Ph#(209) 462-2687 <br /> Lic. No:, 487654 Company Name: Roland Construction, Inc. St: CA ZIP: 95208 <br /> City: Stockton <br /> Address: P. O. Box 8670 334-2332 <br /> DESIGNER INFORMATION Ph#(209) <br /> Lic:No: C044590 company Name: Mike Smith Engineering, Inc• Sl. CA ZIP. 95241 <br /> City: Lodi <br /> Address: P. 0. Box 611 Ph#( ) <br /> LENDING AGENCY <br /> Company Name: ity: gt; ZIP: <br /> C <br /> Address: OFFICIAL USE ONLY <br /> Permit will be issued to an"Owner-Builder Yes❑ No Identification Number. <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 /> DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br /> By my signature below, I certify to one of the following: <br /> lam a California licensed contractor or❑the property owner or E] authorized to act on the property owner's <br /> beh' quires 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 compy with all aws <br /> to <br /> representati eslof this city orrico county to enter the above identified Ip property for ginspection gpurpostion. I authorize <br /> es <br /> ry � <br /> Date G , C <br /> Applicant's Signaturea [nit types <br /> For your convenien checklists d a n itional submittal requirements for various building p Yp <br /> wilding Di <br /> ' on unter. Demolition permit and mobile home on foundation require check- <br /> are available at the <br /> list. <br /> F;\Appiication Forms&Handouts\HANDOUTS\Building Permit Appiication.docPage 1 of 2 <br /> (Revised(07-08-10) <br />