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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 APPLICANT IN ORDER TO APPLY FOR <br />BUILDING PERMITS. <br />Scope of Work: <br />Project Address:g~.s9 Seo.tytfy LVe>t.Y ;;!&r:i</-oN r C)!/9S-21S- <br />Project Valuation:lJ 7'J.,c,(JOo Contact E-mail:-.Jo/l..p;fU)cI(cP ce~O?/';,/1ef <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:zr:»?;/~t)d(Name:.:Totv ?tIGacR <br />Address:t//z z.--r/'o LP;'(l.,/Address:'/IZZ.//'01.£l-e!. <br />City:.s"+0 vk fot-J State:c4 City:S .f~lolv State:e..4 <br />ZIP:rS-Z-O,Ph#(z.0.9)(/~o -,/'617 ZIP:?.J?oc,Ph#(ZOf)Y.I 0 •..Y <(1'1 <br />CONTRACTOR INFORMATION Ph#(ZPJ )1Jo -VI f? <br />Lic.No:100/09 Company Name:JIhP Co~/n{c-1t~15ery,rc.e-f <br />Address:r!2-2-/r<!)u/ef City:.s:focA:"r'qtV St:co ZIP:9.s;;z.o(;:; <br />DESIGNER INFORMATION Ph#('IIb)q~/-3qwO <br />Lic.No:53<b 7~Company Name:~26E iv1("'. <br />~U7 5u~sel-Ave.sf.{~o City:-~jL.5 se (!)4 ZIP:?%2'BAddress:;--~;r <br />LENDING AGENCY Ph#() <br />Company Name: <br />Address:City:St:ZIP: <br />Permit will be issued to an "Owner-Builder"Yes 0 No 0 OFFICIAL USE ONL Y <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 fol/owing: <br />I am 0 a California licensed contractor or 0 the property owner or 0 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 aI/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.0, <br />ApplicanfsSignature ~~Date -*1/ <br />For your convenience checkhsts detalhng 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 Fonns &Handou!s\HANDOUTS\Building Pennit Application.docPage 1 of 2 <br />(Revised (07-08-10)