Laserfiche WebLink
MD ►�DNCc PERW T << PPUCATON <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br />BUSINESS PHONE: (209) 468-3121 <br />INSPEC T iON REQUEST -24 HOUR RECORDER: (209) 468-3165 <br />i� hu-r�r�t� i rvav ayauJ I UL 4'UIVIVI-L ILLY FILLED OUT BY THE APPLiCAN T IN ORDER TO APPLY FOR BUILDING <br />PERMITS. <br />Scope of Work: Pee�F%l y��O'Rdcr� f/ZF ���, �o nn_9 4�5/,W Z <br />Project Address:] J� <br />Project Valuation: 0019 <br />Contact E-mail: <br />OWNER NAME AND ADDRESS <br />APPLICANT NAME AND ADD ESS <br />Name: <br />Name: <br />Address: _. <br />Address: <br />City <br />State: <br />City: <br />State: <br />ZIP: .; <br />Ph#(-.:. } <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: 3- <br />Company Name: <br />dD��U i"Od <br />Address: ) 77 1• PO5 FI /e—City: <br />,,� <br />St: ZIP: S067 <br />LENDING AGENCY <br />Ph#(�r;�) -7 _ <br />Company Name: <br />Address: <br />City: <br />Si: ZIP: <br />Permit will be issued to an 'Owner -Builder" Yes ❑ No <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 />9 am ❑ a California licensed contractor oro'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 peiTnit 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 inspection purposes._ <br />f% <br />Applicant's Signature - - DateFor <br />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:\Application Forms & Handouts\Building Forms and Handouts\Building Permit Application 10-17.doc (Revised (10-6-17)Page 1 of 2 <br />