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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:AlJD (T/O/V ('()8(ISiIN{'")DW~(~G <br />Project Address:83S1 -rRE..I\-SU l<~M~.~c.krn'lJ CA-~51-12. <br />Project Valuation:*7)"l Contact E-mail:J:::/C,USM17lI B~51G Q""'~AJIf:!.r: <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name:NA-IJCY A.51v1 m+Name:~~,-.SMITH- <br />Address:8351 TI JEA-SUf(.E:..AV~.Address:~~Sl TRf:A.sU fU:-A-VE: <br />City:Sfo cl:'Jo "-.!State:CA-.City:mdcro"-J State:CA-. <br />ZIP:qSlIL Ph#(Zoq)CD6/-nDr ZIP:~'5"2(2 Ph#(2Cff)(PCJI-/7()/ <br />CONTRACTOR INFORMATION Ph#() <br />Lic.No:Company Name:o fiUA../£R:... <br />Address:City:St:ZIP: <br />.,,'~ <br />DESIGNER INFORMATION Ph#() <br />Lic.No:Company Name:OWNER... <br />Address:City:St:ZIP: <br />.LENDING AGENCY Ph#() <br />Company Name:O£.uAJ~ <br />Address:City:St:ZIP: <br />Permit will be issued to an "Owner-Builder"YesJ{J No 0 -,;"~-"qFFICIAL 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 PERMIJ f.P~L,I~~~.t~j~~~~~~~~~~:~~'~~~~~~..:.,' <br />By my signature below,I certify to one of the following: <br />I am 0 a California licensed contractor or .l81the property owner or ~uthorized 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 or county to enter the above-identified property for inspection purposes. <br />Applicant's Signature Date <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:lApplication Forms &Handouls\HANDOUTS\Suilding Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)