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ogUt . 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 /> INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> Er>:ou <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: 1v �(� A0W_ C A <br /> Project Address: 9 <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: k, xfbffituName: r <br /> Address: Address: ' <br /> City: ' <br /> �7r State: City: State: 2 <br /> ZIP: C.)' Ph#( ) lea' ZIP: C 6M Ph#( o g,34,1F55z, <br /> CONTRACTOR INFORMATION Ph#( } <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#((pq) 2 <br /> Lic. No: Company Name: <br /> Address: City: i St: — ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <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 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 Vamthorized 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 plication and the information I have provided is correct. <br /> agree to comply with all applica e ounty ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or co nt to enter the above-identified property for inspection purposes. <br /> Applicant's Signature Date r� ° <br /> For your convenlen�e ecklists 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 /> FAApplication Forms&Hand outs%HANDOUTSIBuilding Permit Application.docPage i of 2 <br /> (Revised(07-08-10) <br />