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BUILDING PERMIT APPLICATION Q: �� ,/� •?a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468.3121 C4rfF0•iR�`P INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER To APPLY FOR BUILDING PERMITS. Scope of Work: fJ,—cw OF le, 9a- wo K SCAob✓C Project Address: g274 L/ //w 99 E, g F/?oNmoc $ pL Toy✓ Project Valuation: Contact E-mail: /jJFJ�S�/ 01 focAvV �o S. 0 7 OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: A�rGr E Name: �Uc n (UNSirtVCi/on/ Address: R22 7 Iv //,VC C/t vVH Address: fed ;ox City: LZj,� ()k:0✓t_' State: (j7 City: �TOCXJ State: Cl-) ZIP: Uj56Zy — Ph#(cjlG) ZIP: cjGO� Ph#(2u7 ) 462 - 26X7 CONTRACTOR INFORMATION Ph#(209) 462-2687 Lic. No: 487654 Company Name: Roland Construction, Inc. Address: P. O. Box 8670 City: Stockton St: CA ZIP: 95208 DESIGNER INFORMATION Ph#(209) 334-2332 Lic. No: C044590 Company Name: Mike Smith Engineering, Inc . Address: P. O. Box 611 City: Lodi St: CA Zip: 95241 LENDING AGENCY Ph#( ) Company Name: N Address: City: St: ZIP: Permit will be issued to an "Owner-Builder' Yes ❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to one of the following: I am Ld a California licensed contractor or❑the property owner or❑ authorized to act on the property owner's behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the Information I have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Applicant's Signature % A0014AeR �o sn uCI/o.v Date 1212UZ� For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. HApplicatlon Forms&HandoutsWANDOUTSWullding Permll Application.docPage 1 of 2 (Revised(07-08-10)