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BUILDING PERMIT=DEPAPTMENT <br /> TION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVRTMENT1810 E. HAZELTON AVENCA 95205BUSINES468-3121INSPECTION REQUEST-24 HOUR R468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR <br /> t BUILDING PERMITS. <br /> Scope of Work: S�e S t�V-6? e b("'I 1011"li iz <br /> Project Address: 110 )f (p M t 0J v,,� z ICY', '[ -a C CIA <br /> Project Valuation: {� Contact E-mail:Iduln u F�7 ' I✓, o�L , i7 e <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: GtV1 i �l 1 v I U Name: �, G( uii _I T�v t..v <br /> Address:,(t 0 Z[( V l`i c� l✓ Q Address:;(LJ L[ to _r 4 �Jv <br /> City: 1 o C State: k C Vk City: VG C State: C <br /> ZIP: Ct j 3' � Ph#(5_10) LI 1— ZIP: Ph#( 1c) k b'CU -� <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lie. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lie. 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 U1 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 ❑a California licensed contractor or 1" 1 the property owner or❑authorized to act on the property owner's <br /> behalf(requires written approval and Owndr/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 tocomplywith all applicable county ordinances and state laws relating to building construction. I authorize <br /> representatives of this city or county to enter th 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 /> FMpplication Fortes&Handouts\HANDOUTS\Building Permit Application.docPage 1 of 2 <br /> (Revised(07-08-10) <br />