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qp BUILDING PERMIT APPLICATION SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 BUSINESS PHONE: (209) 468-3121 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: "kA C5 i41>vA Project Address: 7A1 -i c, 1Ac_lul>3L' R,6 2� OJ CA ''S-3 Project Valuation: � W OOO Contact E-mail: OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS Name: W13tiLT iLAtMPS Name: Ot�4q_t,� Gees p Address: ZtlZ3 S. JAe��c I Address: /��5 JA2tGtD City: ?�o� State: G City: &PO State: e ZIP: CS 3('G ZIP: g53�6 Ph#(�c j)ygS (6E 1 CONTRACTOR INFORMATION Ph#( ) Lie. No: Company Name: Address: City: St: ZIP: DESIGNER INFORMATION Ph#( ) Lie. No: Company Name: Address: City: St: ZIP: LENDING AGENCY Ph#( ) Company Name: Address: City: St: ZIP: I� 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 By my signature below, I certify to one of the following: am ❑ a California licensed contractor or❑the-property owner or❑ authorized.to act on the property owner's- behalf(requires written approval and Owner/BuilderVerif!cation Form signed and submitted). I have read this construction permit application and certify the information I have provided is correct. I also�*, e 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. � cJ�� Date �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:lApplication Forms&Handouts\HANDOUTS\Building Permit Application 1-2015.doc Page 1 of 2 ✓ " - .(Revised(01-28-15)