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U'" BUILDING PERMIT APPLICATION <br /> �s'eoc <br /> Z' ➢ ',2 <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> c ' INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> 'QCIFOR�`4 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> Scope of Work: k65144t /,FEZ <br /> Project Address: 4?9/-3 E, U/F 5 j A1100V <br /> Project Valuation: 5/ 5 toc-20 Contact E-mail: "tAglvi' <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: &16m &AILS Name: 4L/C//9 019V/S <br /> Address: Mf L✓, /1)O/P/ Address: 77 y? 6hIV <br /> City: R-l/00N State: (2 City: /Pp if State: 0/.9 <br /> ZIP: 15_3 6G Ph#('Foq) 05--6Sl 1 ZIP: ?Y366 Ph#(2oq) Eos_ _/ <br /> CONTRACTOR INFORMATION Ph#(20q) $/S_ " &/ <br /> Lic. No:7(7 b p:2, Company Name: b0A) L?/1y C0k/lS.7At/C I/0,✓ <br /> Address:—.3 t-/v ).d City: 121 pvti St e�q ZIP: 95-3-37 <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: /V <br /> Address: City: St: 2P: <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 Ka 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 Ile G Date / l2 <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:\4pplication Forms&Handouts\HANDOUTSSuilding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />