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BUILDING PERMIT APPLICATION N SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209)468-3121 INSPECTION REQUEST-24 HOUR RECORDER: (209)468.3165 THE APPLICATION MUST BE-COMPLETELY FILLED OUT BYTHE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. - Scope of Work: LitBr1tiJn Project Address: u4tieh j. 5b&k-hro Cc, Project Valuation: !3 300 Contact E-mail: OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: ntmiN)o Name: Address: C4410 Pol. Address: 77 W Pcddck City: 11A 0"? State: Cq City: 540ek�0- State: r, ZIP: 5aj `J Ph#(102) 7, g 5-9,9 ZIP: 952-/ 5- Ph#(20) 719- 75&78 `CONTRACTOR INFORMATION, -) -7-7 y3$ - 7 7-7 Lic. No: 94.1 Lwo, Company Name: AmplL 141e411 u��z('�� 1 NG Address: Z10 old kto City: y,rwP(I St: Cin ZIP: 015c455 DESIGNER INFORMATION ` Ph#(-, y-o) N3 7-7 7 Lic. No: Wq7 160Company Name: �� r• c Address: ay Qt? City: a We( St: C� ZIP; 9$cl�S LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be Issued to an "Owner-Builder" Yes L] 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 CONSTRl1CTION PERMIT APPLIC_ANT By my signature below, I certify to one of the following: I am 0 a California licensed contractor or Erihe property owner or'L] 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 ate For your convenience checklists detailing 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. R\Applicatlon Forms&Handouts\HANDOUTS\Building Permit Applicalion.docPage 1 of 2 (Revised(07.08.10)