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...,l <br /> �+ SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> : ' 1810 E. HAZELTON AVENUE, STOCKT 1N CA 55205 <br /> BUSINESS PHONE: 205 468-3121 <br /> �rFoM1?/ INSPECTION REQUEST-24 HOUR RECORDER: (208) 468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT I1\1 ORDER TO APPLY FOR BUILDING <br /> _ PERMITS. <br /> Scope of Work: <br /> Project Address: �"- - Imo' s, o t` )_ <br /> Project Valuation: ~' Contact E-mail <br /> OWNER NAME AND 4DDRESS APPLICANT-NAME AND ADDRESS <br /> Name: Na: . Name: �- <br /> Address: Z L< r1 Address: _cl-.5 crr_- � <br /> City: S Iva-1 _State: City: State: <br /> ::7' Zip: <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: 73,4,71., Company Name, <br /> Address: City: St: ZIP: <br /> DESIGNER 1INFORMATION I 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 additio , I authcrize.representatives of this county to enter the above- <br /> identified property for inspection purposes. <br /> Applicant's Signature // . Date <br /> For your convenience checklists detaXji'nd//any dditional submittal requirements for various building permit types <br /> are available at the Building Division coun`tKDemolition permit and mobile home on foundation require check-fist. <br /> F:1Application Forms&Handouts\HANDOUTSSuilding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />