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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 /> q<; oRa` 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: <br /> Project Address: Ceq , <br /> Project Valuation: a 0 0 D Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: /Y ei 4retie / Name: <br /> ✓1.� <br /> Address: C/% 6S,-et, 4, ae� z Address: j>, 0. 13 ox 30/4/ <br /> City: � '� State: City: / e,,-cew State: OA- <br /> ZIP: �� ala Ph#M ) C/ ZIP: 96- Ph#(1,3,/h )Via"/ - <br /> CONTRACTOR INFORMATION Ph#('Zai ) S7S'--L(6§-/ (deq,ce Z�oj_ 4{g/)_©k,ty(6__10 <br /> Lic. No: L.1/,1 el22,-7 Company Name: Goecl / <br /> Address: L-(,?q ( C(ou-Fre,r prrve, I City: sti(;dr— St: 6A ZIP: gS36 <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 /> 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 i ection purposes. <br /> Applicant's Signature V r r� 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:Wpplication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />