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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 />THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APf>t;:ICANT IN ORDER TQ APPLY FOR <br />BUrLDING PERMIl"S.~ <br />Scope of Work:v..hl/~I~f,•.Ill,,,, <br />Project Address:1'i181 I ttJ well'411..4 "'If" <br />Project Valuation:f "~,,,~.IJO Contact E-mail:~tN~~~ltl;'~nt~AN/I.IMt.CI"•OWNER NAME AND ADDRESS APPLICANT NAME AND ADQRESS <br />Name:~/1i o¥~/r ~L ~Name:~".~ <br />Addressj_t;"'AA 7 ~AILP/...~&~Address: <br />City:L.dl/:),State:C4 City:State: <br />ZIP:9§2#~Ph#rz,~~~;3/,e~S-ZIP:Ph#() <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name:/#UL ~--.I.,~•.. <br />Address:City:St:ZIP: <br />DESIGNER INFORMATION Ph#(ZIJ1 )"1~-tlCl '7 ~/()., <br />Lic.No:C~ZZ4';l Company Name:~4t j"'l.n~&"'.11 ~.•~I n <br />Address:7171'1 /1.1'.,,+11,111 AW City:$f'i;/I./1"I <br />St:~ZIP:'1t;1." <br />LENDING AGENCY <br />.....I f'".;: <br />Ph#~), <br />-:"'. <br />Company Name:11.'1 <br />Address:City:St:ZIP: <br />Permit will be issued to an "Owner-Builder"Yes D No D 017s191AL LISE 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 />; <br />DECL~RATION~BY CON~T~~fIION~:pl~~I~A~t,CLC~~T ,;..:~;.~,:':~kt.. <br />~.'.'.'.1::.~~'~'_::Ii.'.. <br />By my signature below,I certify to one of the following: <br />I am D a California licensed contractor or Kl the property owner or D authorized to act on the property owner's <br />behalf (requires written approval and OwnerlBuilder Verification Form signed and submitted). <br />I have read this construction permit application and the information I have prov.ided 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 "",~I':7~Date #~ <br />For your convenience checklists detailing any additional submittal requirements for va ous 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 &Handouls\HANDOUTS\Building Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)