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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 INSPECTION-REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> '�GIFO•Ra\p <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING- <br /> .PERMITS. <br /> UILDING.PERMITS. <br /> Scope of Work: a41A AZ-C 4411 d G ✓77- 4 s le;e,J Tlife 1-lvwfe /SPS Z:A'1 /6—/1 k-�,CF- <br /> ProjectAddress: KA k /'e'0 12D - :sel CA Ts 3 <br /> Project Valuation: Contact E-mail: r rZ ;g -.g� Z eve <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ��d G'l' (�Ci . . L � // Name: <br /> Address: 'LLIS� 5. SES dl Address: <br /> City: <ccn State: City: 1111cE/<'L4:v State: C,4, <br /> ZIP: S 3L Ph#(2,1e0 y7%- $03N ZIP: 4 Ph#(dE� <br /> CONTRACTOR INFORMATION <br /> Lic. No: YYOW s Company Name: Alm <br /> Address: ;20fj cgsr ew ;Vi= a, City: St: eA ZIP: els-5e7l <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 ❑ 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 /> am ❑a California licensed contractor or;j the-property owner or El authorized toacton 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. r 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 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:Wpplication Forms&Handouts\HANDOUTSSuilding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />