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r <br /> BUILDING PERMIT APPLICATION <br /> c �+ SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> �rFOR�`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: la f <br /> Project Address: 3055-4 Ev.. e( V er- 12,5:,(, , �SCaJ <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name h Q Name: V <br /> Address S ( Ver Address: b j if <br /> City: Cj State: City: sem/ &0 State <br /> ZIP: ab Ph#(Z01)6TOI (� ZIP. 9 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name <br /> Address: City. St: ZIP: <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 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 following: <br /> I am ❑ a California licensed contractor or❑ the property owner or);3�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 county ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or county to enter the above-identified property for inspection purposes. <br /> Applicant's Signature I / / - --------_ �� PIS Date /��1f <br /> o_ <br /> Y 9 <br /> For our convenience checklists detailing any additional submittal requirements for variouibullding permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F OUILDIN&HANDOUTS\Building Permit Application.doc Page 1 of 2 <br /> (Revised 1-23-09) <br />