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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) 468-3121 <br /> o'4�t o�iP 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: R,eS od-e-t +(-i <br /> C`Q�j <br /> Project Address: '3011 ( S kO�L1C2 TQocq CfA aS ®4 <br /> Project Valuation: Contact E-mail: k*e , M2 t 1@1 koa •COM <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: eirv-\eA-�) q'Ll Name: k,Zh n e-\ �t ` m2:t I <br /> Address: �b�� S �0 C Address: 3®1t 1 1KOS-tf 2 I? <br /> City:7&0 State: City: TRaG State: CH <br /> ZIP: %bOL4 Ph#(a6y) 561---OS112> ZIP: gs3djL4 Ph#(115) 512)-(LL¢(n.,(,f <br /> CONTRACTOR INFORMATION Ph#(O'16% SGt-4Cli:�>1 <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: fit: 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 E a California licensed_contractor-or[Zlh.e 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 Signatur Date 7— ?- /s' <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 /> FAApplication Forms&Handouts\HANDOUTS1Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />