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BUILDING (HERMIT APPLICATION_ <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> _ 1810 E. HAZELTON AVENUE, STOCKTON CA 95205 <br /> BUSINESS PHONE: (209) 468-3121 <br /> c'tr oR 'o- 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: o X 5at ?,e.<-,S Jv of L S }dYa� e S d 0 <br /> Project Address: ) -7 '3� S' t� thhe50(LJ Lin LOA <br /> Project Valuation: ZZ, 50 o Contact E-mail: <br /> OWNER NAME AND ADDRESS APPLICANT NAME AND ADDRESS C <br /> Name: u t7�2N Jw ' o A/ Name: )t1t 'c1& -4—hie re <br /> Address,: g ±' kthKe50N L� Address: <br /> City: 1od I State' 6L City: Uc t e rr State: <9 <br /> ZIP: Ph#( ) ZIP: Ph#( ) <br /> CONTRACTOR INFORMATION Ph#( –.4 Vlq (p v — 5q y 6 <br /> Lie. No: Company Name: <br /> Address: City: St: ZIP: <br /> DESIGNER INFORMATION Ph#( ) <br /> Lie. 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 ❑ 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 /> 1 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 permit types <br /> are available at the Building Division counter. Demolition permit and mobile home on foundation require check-list. <br /> g F Appijcatiop Forms&HandoutalHANDOUTMuilding Permit Application 1-2015.doc Page 1 of 2 <br />,� '(Rewsed(q1 28 15) <br />