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1___1 <br /> .,. Q 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 /> r PERMITS. <br /> Scope of Work: <br /> Project Address: L , Thm TO in 41 <br /> kc(:(G <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: , iJl ll1/ Name: V /t7l/lf <br /> Address: / j k ENT11(k Address: P j KEN /e/' c <br /> City: /1!M/l/7 F�yCy'� State: C f City: /lfJllf (fi State: Cil <br /> ZIP: r Ph#& ) i( t .3 ` ZIP: �, '] Ph#( -2tj iflt3. 1Tet <br /> CONTRACTOR INFORMATION - Ph#(gip 9) <br /> Lic. No: Company Name: ,S e <br /> Address: I City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: c�� [�E, Company Name: JlxA�t`1�+ ���[ `1 (j[Ul�� � N SIV((—, <br /> Address: I1acJ31 kn4 I city: St: Cd} ZIP: 3�IZ, <br /> LENDING AGENCY fut Ito Ph#( ) <br /> Company Name: SOV I <br /> Address: GT"Yyj. City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes <br /> 71 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 0 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 constrriction 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 /> j �It'1 A <br /> Applicant's Signature a II& d-+ <br /> 'I 'd, <br /> 1� 'IL, d I 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&Handouts\HANDOUTS1Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />