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°o-@ 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 /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> �IFOft <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> //__ PERMITS. <br /> Scope of Work: e-GU h4" ft v.S C :i 4 (JQ a� • S� <br /> Project Address: lq ' SC�X�jn E:SGG <br /> Project Valuation: 57s 06a ContactE-mail: Git/bSa� Ce�2oskClml6 ft��!" �QYj� <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: YY � el W 0 , e>' Name: A, Z �-6 5/+ (j 15'7 GtL WJ <br /> Address: �r e'-amermAddress: Gll°�IAyv <br /> City: State: G City: a�(Ps State: CJ`} <br /> ZIP: qS3 Ph#04Yi) Z7103 `05-( ZIP: gJ53S� Ph#(,261 <br /> CONTRACTOR INFORMATION Ph#()A 5`7& -07,S-0 <br /> Lic. No: /{ s33 Company Name: 658 L�,5'yecfl C 1. <br /> Address: 30b �(�h City: �✓V�CJcIe St:(� ZIP: 9535 <br /> DESIGNER INFORMATION <br /> Lic. No: l Company Name: C�r��-L �� Lr Y/9ft®rC% <br /> Address: AP 0"-41(e3 City: -7'1lldE'S St: Z P: <br /> LENDING AGENCY Ph# S g,7 -- L11& <br /> Company Name: <br /> Address: City: St: ZIP.- <br /> Permit <br /> IP:Permit will be issued to an "Owner-Builder" Yes ❑ No r�( 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 ama California licensed contractor or❑ the property owner or Elauthorized to act on the property ownsr's- <br /> beh if(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 ( Z941L2155F— 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:Wpplication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> j.(Revised(01-28-15), <br />