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BUILDING PERMIT APPLICATION <br /> E + f SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> N; <br /> . 44(EEEEEE111IIVVVIVVV111llliiiiii{{{{{{��`IIIII� , }:, 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> q � BUSINESS PHONE: (209) 468-3121 <br /> 4FOR 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: ` y — A .� <br /> Project Address: /gj S � e-195 jQ <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: - ✓� fZZG Name: 4 %a4l . <br /> Address- _ ✓ �� �� ( Address: /�. <br /> � State: 1111¢ City: ��d State: <br /> Ph#(51D) 5 � Y�Z) zip: 955 Ph#2t > ? <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Z b cJCompany Name: 0— <br /> Address:. 3 Z �t fit � City: 7v e,, St: ZIP: Q� ` <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes ❑ No ki 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❑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 Teed this construction permit application and the information I have provided is correct. <br /> I agree to complywith 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_ 1'( +� �/� Date 2 f� 3 <br /> For your convenience checklists 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:\ApphmUon Forms&HandoutsWANDOUTS\Building Pean@Application.docPags 1 of 2 <br /> (Revised(07-08-10) <br />