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°R '�e BUILDING PERMIT APPLICATION <br /> / a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �i. ,. , { - 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> °92fkoR`°�p 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: /U��J 2_�gt , =twCC Project Address: 1IZv3 t� iv2t i 2 2� <br /> Project Valuation: G7-2 �C-) ContactE-mail: iZC2t?h� Q n2L .JCS�.0.tL •Cv <br /> OWNER NAME AND ADDRESS APPLICANT.NAME AND ADDRESS <br /> Name: 21K j>j0C_L0l-t Name: Qom`( (�)O(LOL ( <br /> Address: ctfOq LJ• Tv2t ,L+Z Q,1J Address: Ljrb i' <br /> City: I-c t , I State: C{l City: LoC> I State: Ck <br /> ZIP: z(5ZL1Z Ph#(70R) ZIP: g5242_ Ph#(?,re, )tO 1 jt rj <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: CA IMN L-1 Company Name: Az" Ci✓Qt�- <br /> Adare`s: lla S w . Ct C�`iELI��� 5': City: St: ZIP: <br /> LENDING AGENCY Ph#(Zo3) LlC.7 o�t 'ZL <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 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 foll�llowwi�ing: <br /> I am r_1a California licensed contractor or Lv_rtne 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 read this construction permit application and the information I have provided is correct. <br /> I agree to comply with all app' ble coun y ordinances and state laws relating to building construction. I authorize <br /> representatives of this city o co my to n er the above-identified property for inspection purposes. <br /> Applicant's Signature r� _ Date (2 .3 y • 13 <br /> For your convenience check¢{ is 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 /> FAApplication Forms&HandoutsWANDOUTSWuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) - <br />