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BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> y` 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> .a. ` BUSINESS PHONE: (209)468-3121 <br /> �i•icoN` 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: <br /> Project Address: n (� Lvir Vl /4 <br /> Project Valuation: Contact E-mail: A tie, e <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: t Name: �4tiM C <br /> Address_ _ �� 1� �C Address: <br /> City: �' �' ,� State: City: State: <br /> ZIP: C ,6, Ph#Vit,,/) q6q'� 6q ZIP: Ph#( ) <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: iCity: St: ZIP: <br /> . <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 athe 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 appliQ�ablecou y ordinang�s and st a laws relating to building construction, I authorize <br /> representatives of this.eity or county to en r the <br /> et5 ve-ide led property for inspection purposes. <br /> Applicant's Signat�ire Date :urge L ars <br /> For your convenience checklists detailing an 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 /> RWppiication Forms 8 Handouts\HANDOUTS\Building Permit Application.docPage t of 2 <br /> (Revised(07-08-10) <br />