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BUILDING PERMIT APPLICATION <br /> RR�jnn SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> eP BUSINESS PHONE: (209) 468-3121 <br /> Pt'icbR`' INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDERTO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: C ' ��- 6 j 1 le..- /rvt-e— <br /> Project <br /> Project Address: `�i o 0.G CA r S-No J <br /> Project Valuation: 6r-22 a q9-- Contact E-mail: (n ' <br /> f ,a• elxcsG' ,rra� • ��� <br /> K <br /> NER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> k �f1QS Name: Qc,,+6 CL <br /> 3 �' 2 Address: �a /V f�^ <br /> 13Y� State:(' CitY: OYl Stater <br /> Ph#(2oq),54`/ J^�J(O( ZIP: 115�J(o(o Ph#(�o�t)S �/✓�l <br /> NTRACTOR INFORMATION Ph#( ) <br /> Company Name: <br /> City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic, No: Company Name: <br /> Address: City: Sf: ZIP: <br /> LENDING AGENCY Ph#( ) <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 owners <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 W 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 �Y , 4.11 �2 a?/ _ Date ( <br /> /7 2J(3 <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 /> F1Applic Uon Fortes&Handouts\HANDOUMBuilding Permit Appllcation.do Page t of 2 <br /> (Revised(07-08-10) <br />