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BUILDING PERMIT APPL15A ®N <br /> ).•�cpG <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> y; { 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> c9<icoN� INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THEAPPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: _nZLA2 <br /> Project Address: (Q 1Z E Ha-ha- In Qd 6�- Js-G 3 a <br /> Project Valuation: Contact E-mail: 1 CA <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: O C 1 O i1m Name: I <br /> Address: a G r� Uv\ da Address: <br /> City: State: City: State: <br /> ZIP: Ph#Q)9) 3 3 q• 6 ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: QQ,N-t-U P <br /> Address: 1�73 City: Vey, Va�(p st: ZIP: 74rY <br /> LENDING AGENCY Ph#( <br /> Company Name: C) )-1 <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 owners <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 orJ4 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 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 purposeess- <br /> Applicants Signature ��--� Date <br /> For your convenience checkl' s 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 /> F:Wppllration Forms HandoutSWANDOUTS\Building Permit Application.docPage 1 oft <br /> (Revised(07-08-10) <br />