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BUILDING PERMIT APPLICATION Q: a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT N yy,��I�I� K 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 458-3121 o'4tik6R" INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING PERMITS. Scope of Work: 2d Project Address: Project Valuation: -7`off Contact E-mail: OWNER NAME AND ADDRESS APPLICANT NA E AND ADDRESS Name: Name: Address: 3 rn �`� Address: City: X State: City: State: ZIP: Ph#( ) , ZIP: Ph#( ) r CONTRACTOR INFORMATION Ph#( ) ` Lic. No: Company Name: l Address: City: St: ZIP: DESIGNER INFORMATION Ph#( ) Lic. No: Company Name e;t Cs� ,* CS(f `Address: © c?a't City: St: C. ZIP: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: Permit will be issued to an "Owner-Builder" Yes ❑ No ❑ OFFICIAL USE ONLY If yes, a completed Owner-Builder Verification Form must Identification Number: be signed and submitted along with copy of the owner's identification prior to issuance of the building permit. DECLARATION BY CONSTRUCTION PERMIT APPLICANT , N By my signature below, ) certify to one of the following: I am ❑ a California licensed contractor or❑ the property owner or❑ authorized to act on the property owner's behalf(requires written approval and Owner/Builder Verification Form signed and submitted). I have read this construction permit application and certify the information I have provided is correct. I also agree to comply with all applicable county ordinances and state laws which govern this project. During the course of construction I will also takes steps to preserve all survey monuments. In addition, I authorize representatives of this county to enter the above- identified property for inspection purposes Applicant's Signature Date � �gs S� For your convenience checklists detailing any additional submittal requirements for various building permit types are available at the Building Division counter. Demolition permit and mobile home on foundation require check-list. F:\Npplication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 (Revised(01-28-15)