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BUILDING PERMIT APPLICATION <br /> N " 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 /> L/pOR`l <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> Scope of Work: <br /> Project Address: 31��� w '�� -CLQ 9 5 7>o L <br /> Project Valuation: Contact E-mail: Q ItqS 5G (11 f��i S�C�c (I 14 i l C,om <br /> OWNER NAME AND ADDRESS nnAPPLICANT NAME AND ADDRESS <br /> Name: e?�S v �iy� 'UCrbUl11 Edi 1�SIo Name: hz'ls <br /> Address: DL{Yrl 4W Address: ':3,k,y fj� <br /> City: State: City: SQv1 FtZ+nG13(O State: CR <br /> -ZIP: q 5301 F Ph#(�4) ZIP: k�ll� Ph#(415 ) 3� orb b <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No 45q -I 11 1 Company Name: S01.6 l Mohs Z")C, <br /> Address: 255k-) qn S'+. u'ik a'69 A City: l�tr( St: (/} ZIP: 1�k71� <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. 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 /> -1 am F1 California licensed contractor or El the property owner or u 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 2 <br /> (Revised(01-28-15). <br />