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BUILDING PERMIT APPLICATION <br /> ri x <br /> N,. lid � •K SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> oat'ikaa�o- 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 /> S c o p e of Work: c 404,6 -4 1- °v4 _ ,'er o6' <br /> Project Address: SSS �� c 6,4,e opj q.53Z . <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: 4,,613 Name: <br /> Address: q72 Vv-d.4 ewiq 41,*y Address: 38/4/ <br /> City: W ,4/_C AJ State: oA , City We_kceni I <br /> State: v <br /> ZIP: C/5 I Z, 0 1 Ph#U00J) 41— V 7;D ZIP: 153Yt I Ph#(SLI) <br /> CONTRACTOR INFORMATION Ph#(2p &44, _ `.A ;7 �g <br /> Lic. No: W4 37 Company Name: 4 LvofAoAfA C- Dd11 s.. <br /> Address: yq,411 A0120'L4_46- City: Z St:64 ZIP: <br /> DESIGNER INFORMATION Ph#(24 ) <br /> Lic. No: Company Name: <br /> Address: . City: St: ZIP: t 111 <br /> LENDING AGENCY Ph#( AJI� <br /> Company Name: - <br /> Address: AOLA <br /> City: St: ZIP: '"Al`q <br /> Permit will be issued to an"Owner-Builder" YesNo ❑ 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 aglf'ee 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 /> 1 .1173 <br /> Applicant's Signature ( " C ��7�° Date t� <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 /> FMpplication Forms 8 Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />