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BUILDING PERMIT APPLICATION <br /> vYs 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 /> VFOR <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> .PERMITS. <br /> Scope of Work: at.,t <br /> of <br /> Project Address `j S"3 v` l Imp l' °l5 3 2— <br /> Project <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: `— Name: -c i <br /> Address: ��s.I _b e2 Address,:( y� - <br /> City: C .� State:_, City: r 6v. State: <br /> ZIP: Gid ( :­�) 2 Ph#(?-pq ZIP: r Ph#Q6,�-() <br /> CONTRACTOR INFORMATION Ph#( ) <br /> _ic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> lfc 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 owner's <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❑ 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 certify the information I have provided is correct. i also agree to comply <br /> with all applicable county ordinances and state laws:which govern this project. During the course of construction I will also <br /> takes steps to preserve all survey monuments. In addition, I authorize representatives of this county to enter the above- <br /> 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-list. <br /> F:\Application Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc page 1 of t <br /> (Revised(01-28-15) - <br />