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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 />PERMITS. BUILDING <br />Scope of Work: TP.444et.de *400171 CC)/•.) <br />Project Address: 1.( .2405' 1140e4.,slat*J Or.434,47 r <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name: et-1-10.a.cio.t, k+001.16-kervms.uooee Name: „televtie. <br />Address: tvz4,5 .-tpozmivn.) pe),413 Address: <br />City: State: State: c.,.„..‘ , City: State: <br />ZIP: 45 -2.451 Ph#(141) 2,44 .- 04( :.2, ZIP: Ph#( ) <br />CONTRACTOR INFORMATION <br />Lic. No: Company Name: <br />Address: City: -.;I: ZIP: <br />DESIGNER INFORMATION Ph#( 96-6.—*‘-606-• <br />Lic. No: C,,upendc- Company Name: ,,,) .Arkrn-ic.,107 iff,,Eve.4.--) 4 <br />Address: eez, . , (Fetee):2e srir. is. City: sTml=taiJ St: cA— ZIP:c74--zol <br />LENDING AGENCY Ph#( ) <br />Company Name: <br />Address: City: St: ZIP: <br />Permit will be issued to an "Owner-Builder" Yes LII No fl <br />If yes, a completed Owner-Builder Verification Form must <br />be signed and submitted along with copy of the owner's <br />identification prior to issuance of the building permit. <br />OFFICIAL USE ONLY <br />Identification Number: <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br />By my signature below, I certify to one of the following: <br />I am L a California licensed contractor or F the property owner or D 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 Signature )‹.---SeWle? Date <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 />FABUILDINGHANDOUTS1Building Perrnit Application.doc Page 1 of 2 <br />(Revised 1-23-09)