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BUILDING PERMIT APPLICATION <br /> N , SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> ' BUSINESS PHONE: 209 468-3121 <br /> r�iii=oR��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: GeifiwY W ,,� Bevn3 coy C <br /> Project Address: ( " �0 U CA- <br /> Project <br /> Valuation: h006no Contact E-mail: 06 q S IS 3 4) 6m,41 <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: \. S! -� Name: / <br /> Address: 10.o C,) C.COi • <br /> / NAa Address: r � <br /> City: \7u S( nG/(a State: eA City: State: <br /> ZIP: �'�3�7 Ph#(,,q) ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <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: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder' Yes 29 No ❑ 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 Verified owner's identification: <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 orthe 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 inspection purposes. <br /> Applicant's Signature Date <br /> For your convenient 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\Building Forms and Handouts\Building Permit Application 10-17.doc(Revised(10-6-17)Page 1 of 2 <br />