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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 />BUILDING PERMITS..~ <br />Scope of Work: <br />Project Address:11505 t.MA'f£~S RD.AC.kAAf()(k, <br />Project Valuation:Contact E-mail: <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name::)Ct.IN'C P,'ut-IP rr'r~~Name:Ev",,~".o V4f.qUQ <br />Address:I~~~'P~Q.Address:1,.,A I "El :>,..•rt ,..j "s+S~Z <br />City:M tit)!fQ.s State:CA City:S.ft,ck.+oi\State:CA <br />ZIP:CfS 035 Ph#(<fCI)'I -Iz.0 z q "3 ZIP:q'E>W z,Ph#(lOf )+-"'/0' <br />CONTRACTOR INFORMATION Ph#(zoY)'4Cf O<=t11 <br />Lic.No:Company Name:C o..M h "o~"- <br />Address:t4~5~Jut\l tier A-ve City:L.oc~.ford St (A ZIP:'f.50~E <br />DESIGNER INFORMATION Ph#(lJr)4-C-;"6(at, <br />Lic.No:""so ~Company Name:FrOJ\k M-La -?:-o,.no <f Assoc,Gt+~ <br />Address:«~3}J.£l D"rdAi'I ~-l-STe:r.City:S+od(+O~StC+ZIP:'f6~OZ <br />LENDING AGENCY Ph#() <br />Company Name: <br />Address:City:St ZIP: <br />Permit will be issued to an "Owner-Builder"Yes 0 No 0 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 />, <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT ,w . <br />By my signature below,I certify to one of the following: <br />I am 0 a California licensed contractor or 0 the property owner or 0 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 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 />F:\Application Forms &HandoutslHANDOUTSIBuilding Permit Application.docPage 1 of 2 <br />(Revised (07-08-10)