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BUILDING PERMIT APPLICATION <br /> a� °K SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> Hue 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> c BUSINESS PHONE: (209) 468-3121 <br /> P. 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: y Q <br /> Project Address: A C 0157- <br /> Project Valuation: f 1700 , tV Con ct E-mail: f vt(,t wL1�IbtR� �i <br /> OWNER NAME AND ADDRESS APPLICANT tid ME AND ADDRESS <br /> Name: v yLk hlA� Name: <br /> Address: + 3$6 ( _ Address: ) A,A t <br /> city`.'q State: r!� City: State: CA' <br /> ZIP: I �j�t� Ph#('�) ZIP: Ph#( <br /> CONTRACTOR-INFORMATION Ph#(W) Q I — r� )q '1 <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 Owner/ButiderVerification Form signed and submitted). <br /> I have read this construction permit application and certify the information I have provided is correct. I also ag4be 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 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 /> Station Forms&HandoutsWANDOUTS1Building Permit Application 1-2015.doc Page 1 of 2 <br />