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1 <br />BUILDING PERMIT APPLICATION <br />c � <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />AM Awl' <br />1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br />`+ :•....• <br />BUSINESS PHONE: (209) 468.3121 <br />INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br />THE APPUCATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br />PERMITS. <br />Scope of Work: � llS � C <br />Project Address: '�� <br />C1 <br />Project Valuation: <br />Contact E-mail: y,_eS,,�,U y &` <br />`( 1 0- C.c1 <br />OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br />Name: `T) aV 6 Lj -1UY-, "e2 Name: '�L� tl �f `_,) ✓d✓�Pel <br />Address: D ���(7)Alf lAddress: 0'7-2- 1V 670 l <br />vi <br />67c-,C 41.,e e1,t . <br />City: Srtoci140✓1 State: 0A City: S-4to , h-ij State: CIA <br />a <br />ZIP: 62-V Ph#(�A) (vv L] ZIP: y5ZG�; Ph#(S <br />CONTRACTOR INFORMATION Ph#(Oy)/-' 99 3 <br />Lic. No: <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />DESIGNER INFORMATION <br />Ph#( ) <br />Lic. No: <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />LENDING AGENCY <br />Ph#( ) <br />Company Name: <br />Address: <br />City: <br />St: ZIP: <br />Permit will be issued to an -Owner-Builder- Yes ❑ No ❑ <br />OFFICIAL USE ONLY <br />If yes, a completed Owner-Builder Verification Form must <br />be signed and submitted along with copy of the owner's <br />identification prior to issuance of the building permit. <br />Verified owner's identification: <br />DECLARATION BY CONSTRUCTION PERMIT APPLICANT <br />By my signature below, I certify to one of the following: <br />I am ❑ a Califomia 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'sSignature�_I%il:< 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.1Application Forms & HandoutsSuilding Forms and HandoutslBuilding Permit Application 10-17.doc (Revised t 10-6-17)Page 1 of 2 <br />