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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 /> oft%F'o'k��o- 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: M. e D tnz . <br /> Project Address: <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: M, 5 \ Name: <br /> ...�Cd. � " ri ,oio. c�wa <br /> Address: 2l1 N Address: 2t� o <br /> City: �oc� � State: City: LJ tate: C <br /> ZIP: °I5 a Ph#(Zcx�) j ZIP: 52t 1Z Ph#(2Cx ) `531 C) 63' <br /> CORACTOR INFORMATION Ph#( ) <br /> Lic. No: N Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: /f/ Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: w/ <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes XNo ❑ 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 ❑ 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 joie above-identified property for inspection purposes. <br /> Applicant's Signat re Date �! k �ly <br /> For your convdnience checklists dbtath g any adAii1knal 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 /> e <br /> u <br /> FAApplicadon Forms&Handouts\HANDOUMBuilding Permit Application.docPage 1 of2 �c <br /> (Revised(07-08-10) - <br />