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BUILDING PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> .c <br /> BUSINESS PHONE: (209) 468-3121 <br /> 4LlFOR�`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: �- l ahem ntti - 6 m c, <br /> Project Address: + 13Q ( Rd <br /> Project Valuation: Contact E-mail �( � , [pVEq�t �jJ Qa� CO n1 <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: I A-q ( � Name: W� 6t <br /> Address: 2 <br /> �)b l: E- C cl. ane 2d Address: 1,93o/ )_. 67aw11 e 1Gd <br /> City: 9va6p, State: aA- City: I-vcichf -\ State:C/1-- <br /> ZIP: Gj�jZ�C� Ph#(; ! FJ I3 72E3 ZIP: IJP /_G Ph#( ) <br /> CONTRACTOR INFORMATION- Ph#(Zgq 5 - 7 Zj <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: n 6h-e- <br /> Address: City: St: ZIP: <br /> Permit will be issued to an "Owner-Builder" Yes ❑ NoOFFICIAL 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/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 agf'ee 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 Mf)'t2-A oed 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 /> ----.F:Wpplication Forms&Handouts\HANDOUTMuilding Permit Application 1-2015.doc Page 1 of 2 i <br /> (Revised(01-28-15) <br /> l <br />