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BUILDING PERMIT APPLICATION <br /> F: I: <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i, 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> °gtiFon 4 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: <br /> Project Address: ri <br /> Project Valuation.10 OCO Contact E-mail: <br /> f OWNER NAME AND ADDRESS APPLICANT <br /> NAME AND ADDRESS <br /> Name: p1� Name: <br /> Address: � Q� Wcvb-�- v Address: <br /> City: Lrv( I State: C� City: ( State: <br /> ZIP: N43 Ph#( ) ZIP: 2 Ph#( ${) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#(`L ) 2j .22 jL <br /> Lic. No: Company Name: ' (( <br /> Address: ,�} 0 City: f - 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 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 ❑ a California licensed contractor or❑ the property owner or E5 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 per it application and the information I have provided is correct. <br /> I agree to comply with all applcounty ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or cc ty to enter the above-identified property for inspection purposes. <br /> Applicant's Signature Date r > <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 /> F:Wpplication Forms&HandoutMHANDOUMBuilding Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />