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BUILDING PERMIT APPLICATION ' SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1I110 E. HAZELTON AVENUE, STOCKTON CA 55205 BUSINESS PHONE: (209) 468-3121 INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 �CIFOR THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: GJ 176Ld Project Address: /y-�i-/3 eel Project Valuation: Contact E-mail OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: t2L-G�.y�Ir�/�//nJ�ts�2fG� ZPJ23, VG�vt : arr�� bSa�G Address:A%,� ,,7 G Address: City: ZgV 1 State: City: State: ZIP: P1#0493 U5- ZIP: Ph#( ) CONTRACTOR INFORMATION Ph#( ) Lic. No: Company Name: Address: City: St: ZIP: DESIGNER INFORMATION Ph#( ) -Lic. No: Company Name: Address: City: St: ZIP: i LENDING AGENCY Ph#( ) j Company Name: 2� z/h'/�J -ly c Z®Zj t&VK Address: City: St: ZIP: Permit-will-be issued to an-"Owner-Builder' YesKNo ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owners identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to one of the following: I am ❑ a California licensed contractor or❑ the property owner or Kauthorized to act on the property owner's- behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and certify the information I have provided is correct. I also agree to comply with all applicable county ordinances;and state laws which govern this project. During the course of construction I will also takes steps to preserve all survey monuments 1n addition, l authorize representatives of this county to enter the above- identified property for inspection p Irk ses. 7 Applicant's Signature 4J� I �i2�?g5�s rzC Date For your convenieno checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check-list. FM;pplication Forms&HandoutslHANDOUTMullding Permit Application 1-2015.doc Page 1 of 2 (Revised(01-28-15)