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BUILDING PERMIT APPLICATION <br /> >.:�_ •gip <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> n BUSINESS PHONE: (209)468-3121 <br /> "CikSR ` 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: tl� -e b ` "1 ig,* 2 wO l."K,� (fits <br /> Project Address: 3 Lr_ _C, <br /> Project Valuation: yl Contact E-mail: <br /> OWNER NAME AND ADDRESS ''// APPLICANT NAME AND ADDRESS <br /> Name: �VIAr Name: �fcfz � �2141` <br /> Address:�kp Z_11(6 Z La- Cc__%sC_ 6 — Address GL (23 e) <br /> City: Cj-Tz-&,C State: City: ti State: e� <br /> ZIP: G j Ph#�"j) `{�/• /S� g ZIP: SZ 3� P () Ye/_faZ 9 <br /> CONTRACTOR INFORMATION 1(d-(_ <br /> Lic. No: S( i Company Name: A two �c <br /> Address: ,,S� � �� City: ` St: ZIP: <br /> DESIGNER INFORMATION Ph#(?j> <br /> Lic. No:d Company Name: r <br /> Lta't T J rP r� <br /> Address:/3 G0 City: Z_csr>( St: ('4ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: 1414 <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 owners <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 D-a'Californla 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 entyr the above-identified property for inspection purposes. / <br /> Applicant's Signature ✓ Date <br /> For your convenience check",vsdetling any additional submittal requirements for various building permit types <br /> are available at the Buildingounter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> F:�Appllc tion Forms&Handouts\HANDOUTMuilding Permit Application.docPage 1 of2 <br /> (Revised(07-08-10) <br />