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BUILDING PERMIT APPLICATION <br /> G SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> { 1!810 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 ORDER TO APPLY FOR BUILDING <br /> PERMITS. <br /> � 3 <br /> 0 <br /> Scope of Work: d�. <br /> Project Address: ' <br /> Project Valuation: j':a f jf Contact E-mall i r:� `4u �; ,. _ ja' " ' ;i <br /> OWNER NAME AND ADDRESS APPLICANT NAME=AND ADDRESS <br /> Name: � p Name: ' # <br /> g <br /> Address: r t - Address. .. $ <br /> City: , ':� State: City: State:- <br /> ZIP: �.. )" Ph#( } ZIP: Ph#(,.. } <br /> CONTRACTOR INFORMATION Ph#( ) <br /> Lic• No: . Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lic. No; r Company Name; � 6 <br /> Address: �..._City: (_... st:Ck ZIP: <br /> LENDING AGENCY Ph#( ) <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 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 orauthorized 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. 1 also agree to comply <br /> with all applicable county ordina es and state laws which govern this project. During the course of construction I will also <br /> takes steps to preserve all sury y�onuments. <br /> : In addition, I authorize representatives of this county to enter the above- <br /> identified property for inspecti n poses• <br /> Applicant's Signature ADate " <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:lApplicatim Forms&Handouts\HANDOUTSOuilding Permit Application 1-2015.doc Page i of 2 <br /> (Revised(01-28-15) <br />