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(c�, <br /> �4�'N• BUILDING PERMIT APPLICATI®N <br /> eSAN 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 /> <tFOR�`P <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> Scope of Work: F <br /> Project Address: (0 O lea 1 C) JQ CLr <br /> Project Valuation: Contact E-mail: fe e ch�l <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: nisi cA Name: �'LiC.i <br /> Address: 61-- T, r Address: 16L 5-5— �^ <br /> City: - 0 n State: City: State: <br /> ZIP: 01 j Ph#(;?Dr/) /69/Zi- ZIP: �Y ;S Ph#(Zd ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. 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 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 or❑ authorized to act on the property owner's- <br /> behalf(requires written approval and OWnerlBuilderVerification Form signed and submitted). <br /> I have read this construction permit application and certify the information I have provided is correct. I also agr4e 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 g/ S <br /> For your convenience checklists detaili any ad itional submittal requirements for various building permit types <br /> are available at the Building Division coun olition permit and mobile home on foundation require check-list. <br /> F:\Appiication Forms&HandoutsMANDOUTSSuilding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />