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BUILDING PERMIT APPLICATION <br /> 1.�.w.�'•.OG <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> 'tV. BUSINESS PHONE: (209) 468-3121 <br /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT'BY THE APPLICANTIN ORDER TO APPLY FOR BUILDING <br /> PE.RMITS.. <br /> Scope of Work C RVI[ } hAF Project Address: 14 a d r! J Z_Z 0 <br /> Project Valuation: Contact E-mail: <br /> OWNER NAMEAND ADDRESS APPLICANT NAME`AND ADDRESS <br /> Name: TA I)ERM 75 , BIRRING <br /> Name: R//i! <br /> Address: IS k 11(f( Address: S I && CI /l t CT <br /> City: /111 A I/TfCd State: Cfi I City: 11A C1?' State: C1-7 <br /> ZIP: Ph# C ) r✓ ©,3J 7tZ ZIP: 53_32 Ph#( 74 4P3 4711 <br /> CONTRACTbR INFORMATION Ph#(Zo q) <br /> Lic. No: Company Name: S <br /> Address: �, City: St: ZIP: <br /> DESIGNER INFORKQN Ph#( <br /> MAT ) <br /> Lic No `d� [OE, Company Name: }.Q(� (� <br /> Address: Lila 0--(-) Tr-M 9L-1p' 4 city: Sr L0 St: Cts} ZIP: <br /> LENDING AGENCY 2! Ph#( ) <br /> Company Name: 1 r- B <br /> Address: City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder" Yes R1 No ❑ OFFICIA6 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 /> DPCLARAT1ON BY CONSTRUCTION PERMIT APPLICANT <br /> By my signature below, I certify to one of the following: <br /> I am ❑ a California licensed contractor or X 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 constrdbtion 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 Signatures nC(A j• i ) i A} Date '7-1S= 24 l.1 <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\HANDOUTS130ding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />