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eo-g"`" BUILDING PERMIT APPLICATION <br /> r�r <br /> r\ K SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> Alf F OR�`P <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> Scope of Work: ' (n <br /> Project Address41 P 7— <br /> Project Valuatic ri Contact E-mail:`MTi 11 (?vcoyv-COQ Qm <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: Qt/ 1fE'41 �, Name: <br /> Address: Ze6weiAd.,bt Address: <br /> ftl <br /> City: L ' State: <br /> CA-City: State: <br /> ZIP: Ph 5-+8 1(3 7'1 ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: Company Name: CWV\RV- <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: eftAk(p <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company_Name: A. <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/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 i sp ction/p'uurp�ose�s t <br /> Applicant's Signature L A/v4 Date �1 4 I (5 <br /> For your convenience checklists detailing Inv additional si mittal 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:\Appiication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> ;::(Revised(01-28-15) <br />