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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 /> 4ttoR�`"� 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: f.1FW CL�gTdPh 2 5T®�y yIP1Gr( � �Aw11L�/ 1�LSfI�PIC.r <br /> Project Address: IFJO T 4-3g1 1217 <br /> Project Valuation: Contact E-mail: Mgt2K(6kAAVI *N(5 60-iAlL• r1 <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: JU6FP1 wo r1PFg6* M®KrAIT Name: "npV C4%%.) <br /> Address: 902-S GUM6112AA IAAAddress: ft ODA <br /> City: W01 State: CA City: 5AL110A State; (4A <br /> ZIP: cl(� 2 Ph#( <br /> CONTRACTOR INFORMATION- Ph#( ) <br /> Lia No: . Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: ,Company Name: K4 j04651 CWN <br /> Address: QD, WA Vy City: 5nL40A <br /> LENDING AGENCY 3f,11q <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 orx 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. 1 also agree to comply <br /> with all applicable county ordinances and state laws which govern this project. During the course of construction 1 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.Ett <br /> Applicant's Signature Date 2231 to <br /> For your convenie ecklists detailing y ad itional submittal requirements for various building permit types <br /> are available at the Building Division counterolition permit and mobile home on foundation require check-list. <br /> FAApplication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />