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BUILDING PERMIT APPLICATION <br /> � •. k SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> c4 BUSINESS PHONE: (209)468-3121 <br /> ........i1` 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: <br /> Project Address: 'Z <br /> Project Valuation: Contact E-mail: C► <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND A/D/DRESS <br /> Name: �'✓l �i Name: � / t/! lL(� <br /> Address- --JCC)q CO\tee kj Sfe -1 Address: .2 SCI SAJ <br /> City: cC���o State: C City: ESc� State: C <br /> ZIP: �j �3�� Ph#�Zf7) IaSs'��G© ZIP: C, `"L �' Ph#(--, 1G�-71W <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address:. City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: 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-Build-er 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❑ 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 laias 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 Applicatbn.dxcpage 1 of 2 <br /> (Revised(07-08-10) <br />