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BUILDING PERMIT APPLICATION <br /> a��•t'f'o.G <br /> Q ?� SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> N] :K 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> 4 ,oaN`p 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: / 737(, <br /> t)'!GL iGr A[ G <br /> Project Valuation: 1,41t5-000 Contact E-mail: ZQ/ rG m <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: W01 &AMName: LOUTS d <br /> Address: 166 -fV114 d Address: j000 AI --UIL, PcL . <br /> City: State: City:G State: Q <br /> ZIP: 1 Ph#( –91 ov,I I ZIP:Cy<i-x Ph#(?6 liy -L dL <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Co 124&1.1 Companny'Name: L/��� <br /> Address: Z?.%I W•March [�G(/JG ,82,00 City: *OGJCf VAq St:ree— zIP9 <ya <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 F in 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 /> By my signature below, I certify to one of the following: <br /> I am F-1a California licensed contractor or Lit/he property owner orX] authorized to act on the property owner's <br /> behalf(requires written approval and Own;r/Builder Verification Fdrm signed and submitted). <br /> I have read this construction permit application and the information I have provided is correct. <br /> 1 agree to comply with pH applicable county ordinances and state laws relating to building construction. [ authorize <br /> representatives of thi ci or county to ter th ve ntified property for inspection purposes. r/ <br /> Applicant's Signa4r Date <br /> For your convenience checklists detailing any additional submittal requirements for va tous buil Ing 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 Appllcation.docPage 1 of <br /> (Revised(07-08-10) <br />