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BUILDING PERMIT APPLICATION e SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 BUSINESS PHONE: (209)468-3121 c /FOR �P INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 � D THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: i'o o_5P MO&C (n e c-St(00 n Project Address: SO C) OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: pnracfa -prod a c-e Name: 1�1;,d- ren 5 f rec c{a r 5 Address: T Address: �� )�,�c% f�„ >d� City: L) State: C 4 City: StC�-e/� , t State: e/4 ZIP: �3 Ph#( ) ZIP: �'S 6 y/5 Ph#V I" CONTRACTOR INFORMATION Ph#(„Zjl�j) _ i Z/ Lic. No: L/j L-c.i of Company Name: M)of - C C'G,15 t<"c f0,r5 AddressAlle6 )o,) City. S[oc NO St. 0/-ZIP: %5.2o5 DESIGNER INFORMATION Ph#( ) :;3q Lic. No: 0 Z4 LI SD /ICompany Name: �/� k e �i.v,,+4i i l ,�� r �• Address: All i 41, ��I, i r P E City: L oL:d St: C)L ZIP:CJ S c/C7 LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder' Yes❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my sig ature below, I certify to one of the following: I am L a California licensed contractor or❑the property owner or❑ authorized to act on the property owner's behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and the information I have provided is correct. I agree to comply with all applicable county ordinances and state laws relating to building construction. I authorize representatives of this city or county to enter the above-identified property for inspection purposes. Applicant's Signature ?2,Z —P Date For your convenience checklists de ing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check- list. ROUILDINGWANDOUTS\Building Permit Application.doc Page 1 of 2 (Revised 1-23-09)