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U'" 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 /> c" INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> 'gtiFOR�`P <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 APPLICANT NAME AND ADDRESS f <br /> Name:,. Name <br /> C.,�. EM: 4 ,ti E , kRf n <br /> v� <br /> Address: �• ' ._ S 4 ��+ t- k "'` ` ` l Address <br /> City: State: City: ( -�-� �- State: <br /> ZIP: Ph#( ) ZIP: e ( cs �: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#(,-;, <br /> Lia No: Company Name: <br /> Address: i /_A" City: St: ZIP: <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 /> 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 ggi``ee to comply <br /> with all applicable county ordinanc"nd•state laws which 9 vern this project. During the course of construction I will also <br /> takes steps to preserve all surveyiY)dnU(nents. In additik i authorize representatives of this county to enter the above- <br /> identified property for Inspecti6J 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 /> r <br /> FAApplication Forms&Handoutsll-IANDOUTSSuilding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />