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BUILDING PERMIT A PL9GATSOH <br />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 />THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br />PERMITS. <br />Scope of Work:e �, <br />Project Address:% ' - G <br />Project Valuation: <br />Contact E-mail: �< <br />, <br />OWNER NAME AND ADD ESS <br />APPLICANT NAME AN ADDRESS <br />Name: L �'� <br />Name: L5/9 _ a <br />Address: Cl <br />Address: <br />City: <br />Stater ✓ <br />City: <br />State: <br />ZIP: ` <br />Ph#(Jfl V� Q <br />ZIP: <br />CONTRACTOR INFORMATION <br />Ph#( ) <br />Lic. No: -76 <br />ompany Name: Q <br />Address: <br />DESIGNER INFORMATION <br />Ph#( ) <br />Lic. No: <br />Company Name: ' �ZI <br />Address: <br />City: <br />St: ZIP: <br />LENDIN GENCY <br />Ph#( ) <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />Permit will be issued to an "Owner -Builder" Yes ❑ No <br />OFFICIAL USE ONLY <br />Identification Number: <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 />DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br />By my signature below, I certify to one of the following: <br />I am<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 an to aws whi vern this\project. During the course of construction I will also <br />takes steps to preserve all survey mon a is In add on, I utIn i e epresentatives of this county to ente the <br />identified property for inspection purp es. <br />� <br />Applicant's Signature Date <br />For your convenience checklists deta ing 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 Fortes & HandoutslHANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br />(Revised (01-28-15) <br />OF <br />