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P4u`" BUILDING PERMIT APPLICATION <br /> Q ; a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 4 <br /> 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209)468-3121 <br /> INSPECTION REQUEST-24 HOUR RECORDER: (209)468-3165 <br /> THE APPLICATION MUST BE COMPLETELY FILLED"OUT BY THE APPLICANT IN{ORDEWTO APPLY:FOR BUILDING <br /> PERMITS. ' <br /> Scope of Work: L— f* 605 rZO-6 �4edZ . <br /> Project Address: /ZL6/ . AW a <br /> Project Valuation: 6ontact E-mail: f� ® ?q�L, <br /> OWNER <br /> NAME"AND ADDRESS`' APPLICANT NAME AND;ADDRESS <br /> �.. v n..✓tA�?r.:.a, -Y,a°. .d,' �1 <br /> Ar. <br /> Name: AM&K41 4A4 Name: <br /> Address:&.45 ' Address: <br /> City:—' ,spy f State: 4?14– City: State: <br /> ZIP: y'S/ Ph#Vi6r) '�/�J3_(v ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION " Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> r: DESIGNER INFORMATION Ph#( ) <br /> Lic. No: Company Name: <br /> Address: City: St: ZIP: <br /> LENDING AGENCY Ph#( ) <br /> Company Name: <br /> Address: City: St: ZIP: <br /> Permit will be issued to an"Owner-Builder" Yes ❑ No F] rt .,OFFICIALUSE ONLY , <br /> If yes, a completed Owner-Builder Verification Form must <br /> be signed and submitted along with copy of the owner's Verified owner's identification: <br /> identification prior to issuance of the building permit. <br /> DECLARATION BY CO SN TRUCTION"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 N 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 ins urpos <br /> Applicant's Sig ature Date /,Z <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:\Application Forms S Handouts\Building Forms and Handouts\Building Permit Application 10-17.doc(Revised(10-6-17)Page 1 of 2 <br />