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BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZFLTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> �_t)�f-''? 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: < <br /> Project Address: <br /> Project Valuation: L r, Contact E-mail: t' f w ckc t 0 -t1n V, 114,AA <br /> OWNER NAME AND ADDRESS APPLICA T NAME AND ADDRESS <br /> Name: `r v& LName: <br /> Address: ��'t� - T Address: <br /> City: eSC�.: rti State: Cp City: `�. State: C/y <br /> ZIP.- Gl -SLS Ph#QCG1 2`l �,��� ZIP: <br /> CONTRACTOR INFORMATION Ph#( } <br /> Lic. No: Lt1-kCompany Name: <br /> Address: t�S t2 i�. ;� A City: St:(N ZIP: <br /> DESIGNER INFORMATION Ph#(,Lir } G-(Ct _ LL <br /> Lic. No: Company Name: SiE:X,: <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 ❑ <br /> OFFICIAL USE ONLY <br /> If yes, a completed Owner-Builder Verification Form must <br /> be signed and submitted along with copy of the owner's <br /> identification prior to issuance of the building permit. Verified owner's identification: <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 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 <br /> For your convenience checklis 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:\Application Forms&Handouts\Building Forms and Handouts\Building Permit Application 10-17.doc(Revised(10-6-17)Page 1 of 2 <br />