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C. 4� <br /> 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 /> c4��Foa% 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 <br /> Project Address: <br /> Project Valuation: - or U Contact E-mail <br /> OWNER+ NAME AND ADDRESS <br /> I APPLICANT NAME AND ADDRESS <br /> Name: �� d ✓, , 1 cel Name: <br /> Address: 1-�o o Address: <br /> City: Lqt0l, State: <,. City: State: <br /> ZIP: Ph#(Zc`j ) ZIP. Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: JlI y g 1k1 <br /> Address: �, IJ ity: p St: <br /> DESIGNER INFORMATION Ph#�p 1Z �— <br /> Lic. No: � �I Company Name: �'S 0- <br /> Address: �, (�, -f L City: o�, St: ZIP 2�/ <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address City: St. ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes ❑ No ❑ <br /> 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 sign re below, I certify to one of the following: <br /> 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 read this construction permit application and the information I have provided is correct. <br /> I agree to comply with all applicable c ty ordinances nd state laws relating to building construction. I authorize <br /> representatives of this city or count enter the Jabo -,deZntifieproperty for inspection purposes. <br /> Applicant's Signature yam _ Date _ I <br /> For your convenience ch klists 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&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />