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BUILDING PERMIT APPLICATION <br /> �III SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE,STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> c INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> �l F_pRN <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: F $ L L <br /> Project Address: ( !'�, ^ 71C Oj I , 1Z YD <br /> Project Valuation: ) 0 C9 n Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Com, L�—6�2 12,G u 1�,,/ Name: S G <br /> Address: \ \ ' S �,,( , 5' Address: <br /> City: L p ) State: C A L City: State: <br /> ZIP: 9 < a Ph#(-k-I tj8'2 --Ic, Lly I ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: rj Z S 7S 1 Company Name: <br /> Address: S v\-� 6 City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: S cx� n 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 9 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❑ 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 (\ , f� <br /> pp ant's Signature_ ._ -'�--'(�/`�- V�/ �'k-q__ _:i) Date � -- \s — 1 <br /> r _ <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:\Application Forms&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />