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BUILDING PERMIT APPLICATION <br /> a I SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> t 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 COMPL TELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> Scope of Work: <br /> _Project AAdres : - <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NA E AND ADDRESS <br /> Name: aj-aName: <br /> Address: 1002 Address: <br /> City: State: City: h State: <br /> ZIP: j 4—� Ph#V_6 �,yr pLd1I ZIP: Ph# O Z''`J� <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: dj�>GI���/— city: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic.No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDI G 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 2authorized to act on the property owner's <br /> behalf(requires written approval and Owner/Builder Verification Form signed and submitted). <br /> 1 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 mon ments. In addition, I authorize representatives-of this county to enter the above- <br /> identified property for inspection purposes. <br /> Applicant's Signature /n` Date 1r <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:\4pplication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />