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0.t 1 �o B IL INS FERMI d APPLICATION 1+ SAN JOAQUIN COUNTY COMM UNITY.DEVELOPMENT DEPARTMENT .y { 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468-3121 c� THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO,APPLY.FOR . BUILDING PERMITS.. Scope of Work: /Z-!kA4A2)A Project Address: tL 1 �.�� E_. /A-',5`flJ-ate !� Project Valuation: z �/y- Contact E-mail: OWNER NAME'AND ADDRESS APPLICANT NAME AND ADDRESS Name: /Rk a�'PI4nf Name: 4 VE 7A Address: E- St4LEKI Address: A l;,r t14�6_5 City: �To f State: City =f e State: ZIP: Ph4#(2a7) �� ., ZIP: 5 CONTRACTOR INFORMATION Ph#( ) Lie.No: 7,l3o� Company Name: Address.-/a6 o� `c3 City: 4 v L "^, St: r , ZIP: DESIGNER-INFORMATION Ph#( ) Lie. No: Company Name: Address: City: St: ZIP: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder" Yes ❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to one of the following: I am [7 a California licensed contractor or ❑ the property owner or ❑ authorized to act on the property owner's behalf (requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the information I have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Applicant's Signature Date ` ' °" :7"/_5 For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. F:1Application Forms&HandoutsWANDOUTSVBuilding Permit Application.docPage 1 of 2 (Revised(07-08-10)