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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 /> �P <br /> 9�l40Ila <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: / l' V\npA21\v\ ' Q11R1 Ur�JjS INTO S`L)6 ,(& 5'1911jI)L1Ji([ eA <br /> Project Address: `{ 1 UQ rT E T Si UCS` &l C 1 <br /> Project Valuation: <br /> Project 3 6/ Q" Contact E-mail: <br /> OWNER NAMEANDADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: P/-)U(- —1 1W A�jA <br /> Address: Address: SS06 QU/�S��tC� RJB <br /> City: State: City: S'-/0 C�_,—o,^/ State: C/j- <br /> ZIP: Ph#( I ZIP: y5 )Z Ph#(p�ei) Lr�z- lQ <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: L300� cim\ !lyuc 107v <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: �(j nJ (� i) rtl�riJ 2 () Y i7Sc:, c� <br /> Address:-V�l N 151-- _ 6Q-11 t�� �} City: St: ZIP: Ci, <br /> LENDING AGENCYPh#(z,j) Lj (,f—6i o b <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 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 ❑ 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 laws relating to building construction. I authorize <br /> representatives of this city o county to enter the above-identified property for inspection purposes. <br /> Applicant's Signature Date <br /> - l z <br /> For your convenience cklis 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 Application.docPage t of 2 <br /> (Revised(07-08-10) <br />