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oe.G t" BUILDING PERMIT APPE5205 <br /> ON <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMEMENT <br /> 1810 E. HAZELTON AVENUE,STO <br /> BUSINESS PHONE3121INSPECTION REQUEST-24 HOUR RECORDE -3165 <br /> 9Ci FOR�� <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> BUILDING PERMITS. <br /> Scope of Work: 1,40 f)J / 4 rL U(-'(-'t C✓ I P f i✓-) LL <br /> Project Address: 35500 T W -T a-/1-� <br /> Project Valuation: -9 10,000 Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ELLi N ) Tho t✓kl " G Name: t9 o ­IA " <br /> Address: _Cc ( (D (u/ r�0 a Iii fqf1 /ZAddress:,26I C%.0C- 4/11 10N TT <br /> City: 'M/✓ C j State: C t1 City:N✓�u T/_- c%l State: C 64 <br /> ZIP: q j 30 Ph#( ) ZIP: 5 3 3 Ph#( ) <br /> CONTRACTOR INFORMATION Ph#01) -2 3 y T & 76 <br /> Lic. No: ` o 7 6 Company Name: PH YJ Tpq P0 J HCl uv)T'1 UL- (rN f�/J 1`V24-10 L( ,rt 0i <br /> Address:,,26I Cr city: ViSt:M ZIPI -3 7 <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 ❑ 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 /> 1 am tLJi 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 county to er the above-identified property for inspection purposes_ 2 <br /> Applicant's Signature Date l 1 (/Q ( / <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 /> FA\Application Fonns&Handouts\HANDOUTS\Building Permit Application.dmPage 1 of 2 <br /> (Revised(07-08-10) <br />