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"Quit, �oG 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 /> 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: N2u., llpipxrrom OG 49A 4 T E <br /> Project Address: // h/ 2!t v�E AA9 <br /> Project Valuation: 13o Contact E-mail: f 6� <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name:ZiacK;e,@�yr�¢ F# ,fp, Name: <br /> Address: N *v Address: 7 <br /> City: as State: City: State: Ci9 <br /> ZIP: gs®?6 Ph#( ) ZIP: Ph#(Roy), 'f(5 � pv <br /> CONTRACTOR INFORMATION Ph#(f10) <br /> Lic. No: Aov $j Company Name: Cpm 57r®.Q~ /!�r,4 <br /> Address: 74/vp City://,v st:c/1, zip: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: flf$'fL Company Name: <br /> Address: 16x51 j� w 4W.,iw ary A4./r city: o st:zjf zip: <br /> LENDING AGENCY <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 /> am (�a California licensed contractor-or❑the property owner or ❑ authorized to act on the property owner's <br /> behaff�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 purposes. <br /> Applicant's Signature Date R/rr�5 <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:Wpplicatlon Forms&HandouWHANDOUTStBuilding Permit Application 1-2015.doc Pagel of 2 <br /> (Revised(01-28-15) <br />