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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 /> °ti�aFeRc��4' INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> Scope of Work: 1 � / <br /> Project Address: Vii, '� L' � ' l9W`4 e5,wr <br /> Project Valuation: © ©( , �' Contact E-mato3s� &,A,%, 662M, <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Name: <br /> Address: ?,O b " CVOW,1 ( Address: <br /> City: ( 4�, State: Ak rW'3J)7\ State: 4k1f 9-J( - ' <br /> ZIP: 2 Ph#(fM) q03, O1;A ZIP: ;5/ <br /> CONTRACT INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: (f 7 6)VO Company Name: <br /> Address: d 6p City: Gj$p St:CA ZIP: �S�Q <br /> LENDING AGENCY Ph#(26c) q1 <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issuee foan "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 owneror authorized to act on the property owner's- <br /> behalf(requires written approval and Owner/Builder Verification Fdrm 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 topreserveall survey monuments. In addition, I authorizerepresentatives of this county to enter the above- <br /> identified property for inspection purposes. <br /> Applicant's Signature G Date Y, �— 2 2 'l <br /> For your convenien ed 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 /> ""�R%15plibetion Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15). <br />