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BUILDING PERMIT APPLICATION <br /> i1 SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i .. .�_ 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> o�<iFoa�o- 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: Zed yov,(2 (/12 H © 7`(e DJ 5 5' 67i <br /> Project Address: ' ( q (�(/ �lc, I l 3� (7d <br /> Project Valuation: IFr ado Contact E-mail: t•e1`fa2 CJ &9 h6f0a�l, Ce Lj <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Q �(/lCItC(� Name: <br /> Address: 1,63117 -_9/y�l/q J5 `!) r- Address: Pr2 gp 50 <br /> City: !/lc U State: City: 511 d a State: CA <br /> ZIP: �S 0 Ph# )lf�(J -Oy-3 ZIP: Ph#(�0 I��SU <br /> CONTRACTOR INFORMATION Ph#( ) c� <br /> Lic. No: Company Name: ��� _ (L eg", <br /> Address: +Ph4( <br /> ty: St: ZIP: <br /> DESIGNER INFORMATION ) <br /> Lic. No: Com77? <br /> . <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address: I J 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 orauthorized 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 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 representativesofthis-county to enter the above- <br /> identified property for inspection purposes. <br /> Applicant's Signature c Date Iz <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 /> FAWpplication Forms&Handouts;\HANDOUTMBuiiding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />