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BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209)468-3121 INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 THE APPLICATION;MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: Project Address: cj , C1523 Project Valuation: 9,55 CCYb Contact E-mail: zhib:wa OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: Name: Address: q - S . NA Address- ,R-712 jRIA City: State: City: State: ZIP: Gl 3I Ph#( ) ZIP: 9 "1 CONTRACTOR INFORMATION Ph#( ) Lid. No: Company Name: Address: City: St: ZIP: DESIGNER INFORMATION Ph#( ) Lie. No: Company Name: Address: City: St: ZIP: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an"Owner-Builder" Yes ❑ No❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certify to one of the following: I am ❑a California licensed contractor or the property owner or❑authorized to act on the property owner's behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and certify the information I have provided is correct. I also agree to comply with all applicable county ordinances and state laws which govern this project. During the course of construction 1 will also takes steps to preserve all survey monuments. In addition, I authorize representatives of this county to enter the above- identified property for inspection purposes. Applicant'sSignatuN92" � en-4-_7 Date For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check-list. R%pplication Foams 8 HandoutsWANDOUTSIauilding Permit Application 1-2015.doc Page 1 of 2 (Revised(01-28-15)