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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 Work:De YVt <9 l V.t ~on of rV1 0 c.-I e v!»r1W II <br />Project Address:S-q S-l/I.J Fi-lcri-twaFt99 £-r:yO It ~(pqP /2fJ(f)r J.. <br />Project Valuation:V\I\(:"AI,'P A'~A v{J \Contact E-mail:"-O m <Z.t-reek>v@~eQsf/~ <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:Th 0 t'Yta:.~.3itf:JQ(e-«Name:1ft 0 IV(tPc,:5i reefer <br />Address:<0:s 7~&1 tU)t\f\J Yf'W<;))f'f Address:{p~75 ~l.-f.-+A I1.j (~wS (;)1' <br />City:~-f o c,~foI State:0/\City:~c IC-h~State:(OR <br />ZIP:qS-ZL~Ph#(2..C1)q <7 s-9 Q;ZIP:«s ?--(Ii Ph#(70~'1S7S-~(")O <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:f\)!\Company Name:•~'i <br />Address:City:St:ZIP: <br />DESIGNER INFORMATION Ph#() <br />Lic.No::tJJ\Company Name: <br />Address:City:St:ZIP: <br />LENDING AGENCY Ph#() <br />Company Name:J'i J'\ <br />Address:City:St:ZIP: <br />OFFICIAL USE ONL Y . <br />Permit will be issued to an "Owner-Builder"Yes D No D <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 />r <br />By my signature below,I certify to one of the following: <br />I am D a California licensed contractor or fsthe property owner or D authorized to act on the property owner's <br />behalf (requires written approval and Own r/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 c~nty to enter the above-identified property for inspection purposes. <br />Applicant's Signature .~~~Date_t{jIJI/ <br />For your convenience checklists detailing a~addi~mittal requirements for various b~lding 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 &Handou!s\HANDOUTS\Building Penmit Application.docPage 1 of 2 <br />(Revised (07-08-10)