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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 />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:\r1S171 tilth j}y)T)f 104'$PL-MH 1J1-Q/WA <br />Project Address:W(oQ1 0,'/....,/.'fJ'y I f?d. <br />OWNER NAME AND ADDRESS .APPLICANT NAME AND ADDRESS <br />Name:H7AYDld JtlVVlDs Name:Valley Permit Services <br />in~~",... <br />Address:'7H1ozs 5.~JLL~f2d.Address:Discovery Bay.CA 94505 <br />?nQ~",.,•.•""""~..• <br />City:~~State:CA ."VI <br />City:State: <br />ZIP:~7?o4 Ph#('2tf1J s r~{Ptlo (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: <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 RJNo 0 OFFICIAL USE ONL Y <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 0 a California licensed contractor or 0 the property owner or 00 authorized to act on the property owner's <br />~behalf (requires written approval and Owner/Builder Verification Fonn 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~Date t;;'~'\\ <br />For your convenience checklists detailing any additional submittal requirements for various building pennit types <br />are available at the Building Division counter.Demolition permit and mobile home on foundation require check- <br />list. <br />F:\BUILDING\HANDOUTS\Building Pennit Application.doc <br />(Revised 1-23-09) <br />Page 1 of2