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BUILDING PERMIT APPLICA ON <br /> t\ r {t SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> R4tri=8R'�4 INSPECTION REQUEST-24 HOUR RECORDER: (209) 468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED OUT BY THE APPLICANT IN ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> Scope of Work: Pew <br /> Project Address: t3;eq O -ttiot7L dU <br /> Project Valuation: +51 4:= Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: *%V(H d k4ILLAs Name: L <br /> Address: 5010 Npg:YL We Address: <br /> City: S'DGmw State: city: State; <br /> ZIP: Ph#( ) ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION- Ph#( ) <br /> Lia No: . Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No: -Company Name: ��l�p *Mm(Lw liew1L PM6Y J <br /> Address: , )1 691 D(, 0 City: e-0D"U/U St: Ch ZIP: 'IS Z-/J <br /> LENDING AGENCY Ph#(201) <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 owners <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 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 Date <br /> For your convenience checklists detailing any additional submittal requirements for various building permittypes <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check-list. <br /> FAApplication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 <br /> (Revised(01-28-15) <br />