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v: Fgl�yf�pl�fl� �I <br />.c <br />QLIFO'R��¢ <br />BUILDING IT APPLICATION <br />N 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 />MUSTBECOMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br />PERMITS. <br />FTH,EPPLICATION <br />of Work: GGEy®.�' z/ /(��j/(/ [a r{�Ysyria 1W&1:;v <br />t Address: &75,e',aKrA/ 9/!C `� �� �7c 0t <br />Valuafionve8dwe �C'v� <br />Contact E-mail: <br />OWNER NAME AND ADDRESS <br />APPLICANT NAME AND ADDRESS <br />Name: 0q_ Gtu/�✓irr�� <br />Name: \ jeep/ rUcL/` <br />Address: 5,/ <br />Address: 0 6gy%7 <br />City: �� <br />State: <br />City: <br />State: <br />ZIP: � � <br />Pn#(z�9) 33�-a/ate <br />ZIP: c/;�_ <br />Ph#(2-y) 1? / n ' 11el / <br />CONTRACTOR INFORMATION <br />Ph#( ) <br />Lic. No: <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />DESIGNER INFORMATION <br />Ph#( ) <br />Lic. NoCoif ,�o <br />Company Name:d' <br />Address: j /V ��jj��,` <br />City: <br />St: G//1 ZIP:W��V <br />LENDING AGENCY <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />Permit will be issued to an "Owner -Builder" YesM No ❑ <br />If yes, a completed Owner -Builder Verification Form must <br />be signed and submitted along with copy of the owner's <br />identification prior to issuance of the building permit. <br />OFFICIAL USE ONLY <br />Identification Number: <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br />By my signature below, 1 certify to one of the following: <br />I am ❑ a California licensed contractor or ❑ the property owner ors[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 � es <br />Applicant's Signatur � Date <br />For your conv ` t e 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 />Permit Application 1-2015.doc Page 1 of 2 <br />