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BUILDING PERMIT APPLIGATI®N <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> c BUSINESS PHONE: (209) 468-3121 <br /> o�iiPSRf'r INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165- <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THEAPPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: A9W SFIZ <br /> ,/ <br /> Project Address: 3®U "1 '�I{7�nSS0- <br /> Project Valuation: Contact E-mail: �j IVwV(yt , <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> ame: `q185- r V v4 . DR .. Name: <br /> Address: y1j�(� Address: \ <br /> City: I V State: City: ff State: <br /> ZIP:� � r Ph# ZZr'S7 to ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Stwc�;_ I Company Name: 04-b'4S Pluvi, 111 �U <br /> Address:. q/8 S Y)14 V'AI(e qtZ- City: IG0_5eVt Sto+-ZIP: J�-4( <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 ❑ 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 Tead this construction permit gntyordinan <br /> on and the information I have provided is correct. <br /> I agree to comply with all applicab and state laws relating to building construction, I authorize <br /> representatives of this city or c nr the ova-i ntified property for inspection purposes- <br /> Applica ' �! /2 - /G - /3 <br /> nt'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:\Application Forms&Handouts\HANDOUTS\Building Permit Application.docPage t of 2 <br /> (Revised(07-08-10) <br />