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°t4U' BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT ` 1810 E.HAZELTON AVENUE,STOCKTON CA 95205 BUSINESS PHONE: (209)468-3121 SRC%ppFi�`P i INSPECTION REQUEST-24 HOUR RECORDER:(209)468-3165 THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: 1/, k Project Address: { '7'T� fi t 11 ft- 1 E OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: — Name: Address: Address: City: '� d D �, State: City: State: ZIP: Z Ph#(7� ��] —��.,? ZIP: Ph#( ) CONTRACTOR INFORMATION Ph#( ) Lic. No: 63 C) Company Name: /t rGT(Cj�i _ �`� Address: r �r7 ` 1`� f� i1't City: C �_� _T C;i., St: ( ZIP: DESIGNER INFORMATION jPh4( ) Lic. No: Company Name.- Address: ame:Address: L , City: St: (A ZIP:(_j Z03 LENDING AGENCY Ph#("),�) -145 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 signature below, I certify to one of the following: I ama California licensed contractor or jN the property owner or El 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 nter th above-i entified property for inspection purposes. Applicant's Signature ' w- I- — Date_ 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. F:18UILDINGWAND0UTS1Bui1ding Permit Application.doc Page 1 of 2 (Revised 1-23-09)