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BUILDING PERMIT APPLICATION <br /> .G <br /> v' `a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E.HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> Yi o INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE=APPLICATIOWMUST.BE COMPLETELY FILLED;OUTiBY THE,.APPLICANT:IN.ORDER.TO APP,LY'FOR <br /> BUILDINGPERMITS. <br /> Scope of Work: -Z ll lQ 4ya (0 9 <br /> Project Address: l� <br /> Project Valuation: Contact E-mail: <br /> OWNER;NAME'ANDADDRESS APPLICANT'NAME`AND,;ADDRESS . <br /> Name: rIJdGL 04, elY Name: <br /> Address: j&,7I- az9 C Address: 71291k '141i <br /> City: ES State: C1q. City: 5'14 /; C State: 1q. <br /> ZIP: 96-310 Ph#V69) 070-(oD y3 ZIP: 95 alp � Ph#olfl c1q�'�f7c7 S <br /> CONTRACTOR.INFORMATON: Ph#( ) <br /> Lie. No: Company Name: W/[)-P r U ICS e� <br /> Address: City: St: ZIP: <br /> DESIGNE '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 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'AP,PLICANT. <br /> _ . <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 unty to enter the above-identified property for inspection purposes. <br /> Applicant's Signature C / �_ Date Sl/sl/l5 <br /> For your convenience ecklists detailing any additional submittal requirements for various building permit types <br /> are available at the B ding Division counter. Demolition permit and mobile home on foundation require check- <br /> list. <br /> R\Applicalion Forms&Handouts\HANDOUTSWuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />