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ours p p ®®®® {{��,,¢¢a� //�� ��{{�� <br /> e �c� B <br /> UILD If�91ltl�� �9i"9 �6�e/"!��®tl�l <br /> U ` ' COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E.HAZELTON AVENUE,STOCKTON C A 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> PECTION 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: <br /> Project Address: <br /> Project Valuation: C Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS <br /> Name: C 1) <br /> Name: <br /> Address: Address: <br /> City: <br /> Y State: City: State: <br /> ZIP: QS Ph#( i) �- z7 ZIP: Q 153 3-) Ph#� <br /> fi ) g2 <br /> CONTRACTOR INFORMATION Ph#(2�) Z <br /> Lic. No: 5Company Name: \ <br /> Address: <br /> CI Ir City: St:C* ZIP: <br /> DESIGNER INFORMATION Ph#( } <br /> Lic. No: Company Name: <br /> Address: City: <br /> St: ZIP: <br /> LENDING.AGENCY per( ) <br /> Company Name: <br /> Address: City: <br /> 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 thep r <br /> operty <br /> behalf(requires written approval and Owner/Builder Verification Form signed and submitted). owner's <br /> I have read this construction permit application and certify <br /> with all applicable county ordinances and7n . <br /> laws whgovern this project the information I vDu ng the e provided rcourse of construction I will lsorrect. I also agree to y <br /> takes steps to preserve all suryey monu In addition, I authorize representatives of this county to enter the above- <br /> identified property for inspection pure <br /> Applicant's Signature <br /> Date <br /> For your convenience checklists detailing any add onal submittal requirements for various buildin <br /> are available at the Building Division counter. Dem n permit and mobile home on foundation require check l <br /> ' ' ist. <br /> F:lApplicatlon Forms&HandoutsUANDOUTS113ullding Permit Application 1-2015.doc <br /> (Revised(01-2&15) Page 1 of 2 <br />