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COUNTY OF BUTTE - DEPARTMENT OF DEVELOPMENT SERVICES - BUILDING DIVISION
7 County Center Drive -pO�roville, California 95965 * Telephone (5391) 538-7541 g PERMIT NO.
(Rev. 12/96) APPLICATION AND PERMIT � 0
ASSESSORPARCELNUMBER '^ ,�
J
ZONING
BUILDING PERMIT
OWNER. TELEPHONE l
SQ. FT. OCC. BUILDING VALUATION
OWNER'S MAILING ADDRESS �
CONTRACTO NT�4E •� P ONE
-�JG
1
CONTRAC 5 MAILING RESS
CONSTRUC(I LE s� b
Fireplace
LENDER'S MAILING ADDRESS
Total Valuation $
ARCHITECT OR ENGINEER LICENSE NO.
—Filing Fee
$ 20.00
Permit Fee
$
ARCHITECT OR ENGINEER'S MAILING ADDRESS
Plan Checking Fee
$
BUILDING ADDRESS
Energy Plan Checking Fee
$
$
PERMIT FEE
$
LOT NO.SUBDNISION'S NAME PARCEL MAP
PLUMBING PERMIT
Fling Fee 20.00
Each Trap
7.0023.00
USEOFSTRUCTURE
Solar or heat pumpwater heater
SF ❑ Duplex ❑ Mobilehome ❑ Other
Water piping
15.00
SPECIFY
Each gas water heater or vent
15.00
TYPE OF WORK
Gas piping system 1 - 5 outlets
15.00
New ❑ Addition ❑ Remodel ❑ Utilities O Installation ❑ Other ❑
Building sewer
.15.00
Mobile Home I S I G I W
@20.00
Describe Work:
PERMIT FEE
S
ELECTRICAL PERMIT
Fling Fee 20.00
E0
Main Service 200A0V OROR LELES'S
23.00
Main Service TO
46.00so
LICENSED CONTRACTOR'S DECLARATION
CCU000A
NEW CONST. DWELLING OCCUP.
DWE200ALLING
(
SO
3.5¢FT:
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
OR ADDNS. 8 ACC. BLDS.
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code,
NON-HEOSID. MULTH CIRCOUTLUITS
@7.50
and my license ' in full fo a and effect. ��(�
3
POWER APPARATUS
�p ��
License Class Lic. No. l:r/25(a
S SINGLE OUTLET CIR.
20 @IDD
_
OWNER -BUILDER DECLARATI
EX. Occup. OUTLET OR FIXTURES
BAL@ .50
I hereby affirm under penalty of perjury that I am exempt from the Contractors License
FIXED APPLNS. OR
Ex. Occup. ouTLETs RESID. E0.
S.00
Law for the following reason:
Temporary Service
23.00
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Mobile Home Facilities
20.00
will do the work, and the structure is not intended or offered for sale.
❑ I, as owner of the property, am exclusively contracting with licensed contractors
Misc. Wiring
23.00
to construct the project.
❑ 1 am exempt under Sec. Business and Professions Code for this
PERMIT FEE
$
reason
WORKERS' COMPENSATION DECLARATION
MECHANICAL PERMIT
Filing Fee 20.00
I hereby affirm under penalty of perjury one of the following declarations:
Heating
❑ 1 have and will maintain a certificate of consent to self -insure for workers'
Cooling
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Hood
6.50
❑ I have and will maintain workers' compensation insurance, as required by Section
Ventilation
3700 of the Labor Code, for the performance of work for which this permit is issued.
My workers' co a satin insure ccarrier d policy nuC_qber are:
Carrier
PERMIT FEE
$
Policy Number
Mobile Home Installation Fee
$
(The above sections need n e completed if the permit is or work of a valuation
Energy Inspection Fee
$
of one hundred dollars ($100) or less.)
❑ 1 certify that in the performance of the work for which this permit is issued, I shall
occ CONST. TYPE
TOTAL FEE $
not employ any person in any manner so as to become subject to workers'
compensation laws of California, and agree that s ould become subject to the
HAZ. I D. FEES IMP I FLOOD
CDF PARCEL PD HD ISS
w rs' compensations o sectiV37of the Labor Code, I shall
orthw h comply with thon
This permit is hereby issued under the
applicable provisions
of the Butte County Code and/or
Resolutions to do work
X
indicated above for which fees have
been paid.
Signat e o App ca��5Nv_vContractoent
An OSHrmit is required for excava i ns over 5'0" deep and demolition or construction
Da /03
of structur over 3 stories in height.
Y
BC
e
(P -5 X
ReceiptNo.
PERMIT EXPIRES O
WHITE-D.D.S.-B.D. CANA Y -A SESSOR PINK -INSPECTOR GOLDENROD -APPLICANT
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