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ip <br /> BUILDING PERMIT APPLICATI®N <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: <br /> Project Address: <br /> Project Valuation: Contact E-mail: <br /> OWNER NAME AND ADDRESS gAPPLICANT NAME AND ADDRESS <br /> Name: '64 yN'✓q • i9 vl� Name: ,U k YA 1(,) 419 1,1/.S <br /> Address: 17-2 ?q F_ • t✓fS/r ti Address: 5717 <br /> 7 F, es,;_ 911,60V <br /> City: Qf/00,✓ State: City: ki/00/(/ State: C <br /> ZIP: S'3 66 1 Ph#( ) ZIP: ,S73 6 U Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic. No: 7 b Y &02 I Company Name: ,j'oq/g6/.� (20g/sf te t,CC_101V . <br /> Address: 3y0 S. PSC /F/C City:-s9 Ni�C4 St:(T( ZIP: <br /> DESIGNER INFORMATION Ph#(2,vq) $'/S- <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 /> I am ❑ a 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 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\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />