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s° o BUILDING PERMIT APPLICATION <br /> ;G <br /> ¢ , SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 'Itt1a E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> °5t l 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: <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ,J a ert I Name: r- <br /> Address; L r"2t�1 R ,A_ Address: �Z�t <br /> City: State: GN , City: JJ�State: GtA , <br /> ZIP: irK� '-3 6(, Ph#( b1 ~ �'3 ZIP: ~'S 5-3 <br /> CONTRACTOR INFORMATION Ph#( ) <br /> L ic. No: Company Name! <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> --Lic. No: s Company Name: g,6V�� <T ��1ti�S�rlk_ <br /> Address: LAS'? 1 Is k City: 1I���r � 7St--t/- Z'P: pt -3 <br /> LENDING AGENCY Ph#at�� <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, l certify to one of the following: <br /> I am ❑ a California licensed contractor or 2 the property owner or❑ authorized to act on the property owner's- <br /> behalf(requires written approval and Owner/Bui[derVerification Form signed and submitted). <br /> 1 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..._ln.addition, 1.authorize.rep res entatives of this county to enter the above- <br /> identified property for inspection purposes. <br /> Applicant's Signature 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:1Application Forms&HandoutslHANDOUMBuilding Permit Application i-2015.doc Paged oft <br /> -28-15) <br /> (€tevised t01 <br />