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BUILDING PERMIT APPLICATION <br /> >r•�� °4 <br /> m C I K SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1 � 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> l> BUSINESS PHONE: (209) 468-3121 <br /> cq"';`•"'�`P INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> <IFOR <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: I�, a a� <br /> Project Valuation: Contact E-mail: <br /> WNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: ti �� r��C3 Name: ,J�)l�7 <br /> Address: 13 6 77 Address JJ <br /> City: State: City: J State: / <br /> ZIP: Zj Ph#(qQf 6g-4 ZIP: ��� Ph# ) <br /> CONTRACTOR INFORMATION Ph _( ) <br /> Lic. No: 0 CRS OtA J Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDIJNG 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 du tae <br /> laws which govern this project. During the course of construction I will also <br /> takes steps to preserve all survey m uments. In addition, I authorize representatives of this county to enter the above- <br /> identified property for inspection p above- <br /> os <br /> Applicant's Signature DateLS <br /> For your convenience checklists detailing any additional submittal requirements for variou building permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check-list. <br /> F:\Application Forms&Handouts\HANDOUTSSuilding Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />