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BUILDING PERMIT APPLICATION <br /> e' ?� SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> �4��FORN`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: <br /> Project Address: I 1`7(� ( �w <br /> Project Valuation: a Co v Contact E-mail: 6"I uJQ 'o, <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name; ,s h /20 e /3ti Name: <br /> Address: 117 , y f� Address: 10, L). i?b* S—Z, <br /> City: S .3, t State: C City: 6th State: C [1- <br /> ZIP: Ph#( ) ZIP: Ph#op ) 8-to -O e, <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: g 3� ( (p Company Name: y �o C w <br /> Address: i� C) (�O � (p City: St:c w ZIP: 0 <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: company Name: �, I 2 <br /> Address: 3 { City: , \t St:c� ZIP: <br /> LENDING AGENCY Ph#() ) (o - 7`JS cP <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder"Yes ❑ No GAJ 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 [g 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 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_l�� Date a % <br /> For your convenience checklists 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:\Applicalion Forms&Handouts\HANDOUTSOuilding Permit Application.docPage i of 2 <br /> (Revised(07-08-10) - <br />