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BUILDING PERMIT APPLICATION <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br />BUSINESS PHONE: (209) 468121 <br />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: 2 �/ C <br />Project Valuation: 2 �j (] <br />Contact E-mail: , _0 5 ci <br />OWNER NAME AND ADDRESS <br />APPLICANT NAME AND ADDRESS <br />Name: i , s t . �� — ��r F i C� <br />Name: <br />Address:o % 7 <br />Address: <br />City: (� <br />State: C <br />City: <br />State: <br />ZIP: C? S <br />Ph#( -2s= -n C�C� _� �� <br />ZIP: <br />Ph#( ) <br />CONTRACTOR INFORMATION <br />Ph#( ) <br />Lic. No: <br />Company Name: <br />Address: <br />City. <br />St: ZIP: <br />DESIGNER INFORMATION <br />Ph#( ) <br />Lic. No: <br />Company Name: 40,1JO 17 P v � <br />Address: Eel -,-1171111 <br />CI . 4S <br />St: ZIP. 5207 <br />LENDING AGENCY <br />Ph#( ) <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />Permit will be issued to an "Owner -Builder' Yes NoP61 <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. <br />Verified owner's identification: <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br />By my signature below, I certify to one of the following: <br />r. <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 OwneilBuilder Verification Form signed and submitted). <br />I have read this construction permit application and certify the information 1 have provided is correct. I also agree to comply <br />with all applicable county ordifi-dnces and state laws which govern this project. During the course of construction 1 will also <br />takes steps to preserve all survey monuments. In addition, I authorize representative< of this county to enter the above - <br />identified property forin ctiori%pu�rpos <br />les. ` <br />Applicant's Signature , /� !. `i, 1 / L L 1rc ^ 1 �� 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 />FAWlication Fortes & Handouts\Building Fortes and Handouts\Building Permit Application 10-17.doc (Revised (10-6-17)Page 1 of 2 <br />