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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 /> cq$iKOR.+` INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> =: THE APPLICq?ION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> "'Scope,,,of Work: PJB <br /> , <br /> €'ro�ecfi:,,ddres5 (e 7- 5_7 Lo J U� <br /> e aluation: Contact E-mail: + <br /> pWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> fg L Name: TU 6 <br /> s ` .6t Le a c Address: 2-7S <br /> r c� State: City: tate: <br /> 17 Ph#( ) ZIP: Ph#(!j-(t) C? <br /> -, CONTRACTOR INFORMATION Ph#( ) <br /> No: Company Name: <br /> address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> _ .Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Nar-ne: <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 signatu rg 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(requi res written approval and Owner/Builder Verification Form signed and submitted). <br /> I have read th is construction permit application and certify the information I have provided is correct. I also agree to comply <br /> with all applicaple county ordinances and state laws which govern this project. During the course of construction l 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 /> 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:\Application Forms&Handouts\HANDOUTS\Building Permit Application 1-2015,doc Page 1 of 2 <br /> (Revised(01-28_15) <br />