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BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541 FAX#: (530)538-2140
WEBSITE: www.buttecounty.net\dds
PERMIT NO.
BP051719
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of Division 3 of
Issued Date: 06/30/2005 APN: 007-150-105-000
the Business and Professions Code, and my license is in full force and
effect.
Site Address: 1069 E EATON RD CHI
License Class : License Number:
Map Index:
Date: Contractor:
Description: RE -ROOF (14)
OWNER43UILDERDECLARATION
I hereby affirm under penalty of perjury that I am exempt from the
Contractors' State License Law for the following reason (Sec. 7031.5
Business and Professions Code: Any city or county which requires a
Owner: STURGIS CHARLES EDWiN'^"'"'permit
to to construct, alter, improve, demolish, or repair any structure, prior
1069 EATON RD
to its issuance;~also requires the applicant for such permit to file a
signed statement tfi'at he or she is lice nsed� pdfsuant td.the•provisions of:
" CHICO, CA '
the Contractor's State License Law (Chapter 9 -commencing with Section
95973-9131 +
7006);of Divisior'3.of the'Business and Professions Code) or that he or
she'is' exempt therefrori''and the basis,for..;the alleged exemption, Any
violation of ,'Section. 7031.5 by any applicant for a permit subjects the
applicant to.'acivil,pe.. of not more than five hundred dollars ($500).): .
I, as o'wner•of the property, or my employees with wages as their
sole compensation, will do the work, and the structure is not
tjntend@.do,offsled.for,sale.(Sec:�7QaawBusineseand.Professions_
Applicant: STURGISCHARLES.,EQWI,N„•,,,,,.,.,�_ •,,�.,,,.,.,,__ ,
Code: The contractors -,State' License: Law does not apply to an
1069 EATON RD
owner of property who•„builds or,improves:thereon, and.who does
CHICO, CA
such work himself or,•herself.or, through -his or her own employees,
provided that such improvements, are not intended or offered, for
95973-9131
sale. If however, the building or improvements are sold within one
year of completion, the owner -builder will have the burden of
proving that he or she did -not build or improve for the purpose of
sale.).
0•-•,1, as•:•owner,,:of ,the;:.property,,,,am.�,exclusivelywcontracting •,with.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code. The Contractors' State License Law does
Contractor:
not apply to an owner of property who builds or improves thereon,
and who contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
❑ .,I am xempt.under Article and Pro s ions'Code
Dater Owne A;eB'ess
License #: -”
WORKER$:.COMPENSATION DECLARATION
I hereby affirm under'penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -insure for
- -
workers' compensation; as provided for by Section 3700 of the
Architect:
Labor Code, for the performance of the work for which This permit
is issued _:....
Engineer:
❑ 1 have and will maintain° workers' compensation insurance, as
required by Section 1700 the Labor Code, for the performance of
-the work for which this permit is issued. My workers' compensation
insurance carrier and policy, number are: .
Carrier:
Total Square Ft: 0 S. F.
Valuation: $0.00
Policy #:
... �, • ,.....
Census Code:
❑ 1 certify that in the performance of the work for which this permit is
issued. I shall not employ any person in any manner so as to
become subject to the workers' compensation laws of California,
and agree that if I should become subject to the workers'
„,...., .,
compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions.
Date:
Applicant: "
((//��
4312 \1J� '
WARNING:,— Failure to secure workers' compensation coverage is
unlawful, and.shall.subject an employer to criminal penalties and one
hundred thousand dollars ($100,000), in addition to the cost of
compensation, damages as provided for in Section 3706 of the Labor
code, interest„and attorr:ey's.fees., ...-... • .. - <... ...
---- :._ ..
CONSTRUCTION LENDING AGENCY
This permit is hereby issued under the applicable provisions of the Butte Cnunty Coda anNor
I hereby affirm that there is a construction lending agency for the
Resolutio s to do work indicaMbover which fees have been paid.
performance of the work for which this permit is issued (Sec 3097 Civ.)
Name:
BY Date: ( �J lJ✓
PERMIT EXPIRES ON: 06
Address:
Date
❑ I hereby certify hat tthe use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage,
handling and use of hazardous materials.
❑ Notification in accordance with Section 19827.5 of California Health 8 Safety Code is not applicable to the scheduled construction of this project.
❑ Attached are copies of the required E.P.A. notification forms.
I hereby certify that I have read this application, that the above information is correct, and that I am the owner or the duly authorized agent of the ner. 1 agree to comply with
all county and state laws relating to building construction. I acknowledge. it is unlawful to alter the substanc y official orm or d ment of It County. I hereby
authorize representatives of Butte County to enter upon the above mentioned property for inspection pu
Print Name- � :-0 7Tr- - Signature
Date:
Owner 0 Contractor ❑ Agent for Owner 0 Agent for Contractor
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATION
AND SUBMITTAL REQUIREMENTS
24 HOUR INSPECTION#: OROVILLE: (530) 538-7636 • CHICO: (530) 891-2834
OFFICE #: (530) 538-7541
A FEE WILL BE REQUIRED AT TIA1E OF APPLICATION
Website: www.buttecounty.netldds
**PLEASE PRINT CLEARLY**
it
OWNER
Last Name
s
Fi t Name
Address
IV _(
(1
City
State
State
Zip 7�
Phone
,6-3,0
Fax D _ L -Z
E-mail//
da r
t o Q B a if
it
APPLICANTSI NATURE
For office use only:
CONTRACTOR
Name
s
Address
a-
City
I No
State
Zip
Phone
o qg
7
Fax
E-mail
Planner
Lic. #
Class
APPLICANTSI NATURE
For office use only:
ARCHITECT/ENGINEER
Name
s
Address
a-
City
I No
State
Zip
Phone
o qg
7
Fax
E-mail
Planner
State License Number
APPLICANTSI NATURE
For office use only:
APPLICANT NAME
Name
s
Address
a-
City
I No
State
Zip
Phone
o qg
7
Fax a
E-mail /
fl0.r
Planner
APPLICANTSI NATURE
For office use only:
Zoning
Property Address
Flood Zone .I
I
SRA
I Yes
I No
Occ.
Type Const.
Subdivision Name
Map Book
Page
Lot #
Planner
Date Approved:
OVER FOR SUBMITTAL REQUIREMENTS
811) KAFORMS\BUILDING FORMS\BldgApplSubRgmts.doc
PERMIT
NO.
BIN #
LOCATION
AP#
Property Address
City
t_ o
Cross Stre t
J
WORKER'S COMPENSATION
Policy Number
Carrier
If hiring anyone other than license contractors, a certificate of worker's
compensation must be shown at the time of permit issuance.
LENDING AGENCY
Name
Address
Description or Scope of Work:
RIF S LE o 0
41 MgzeL OL -h5
Sq. Footage CS
❑ Structure Built without Permits
❑ Proposed Change of Occupancy
(Note previous use):
EXPIRATION OF APPLICATION
Applications for which a permit has not been issued will expire one
year after the date of application. In order to renew action on an
application after expiration, a new application, plans and fee will be
REQUEST FOR REFUNDS
Refunds can only be made upon written request by the person who
paid the fee. The request must be made prior to the expiration of the
permit and no construction work has been done. Filing fees, plan
check fees for work plan checked and other department costs are not
refundable.
Page 1 of 2
SMIP
Date: G( • 3o • U S O Other I
Total
REV 2-24-05
11"
Received by: �j . Amount:
�l
l0 • Bldg
SRA
Receipt #:q 3 l�
Sheriff
Page 1 of 2
SMIP
Date: G( • 3o • U S O Other I
Total
REV 2-24-05
SUBMITTAL & PERMIT REQUIREMENTS
The following drawings and specifications must be submitted to the Building Division in order to apply for a
permit. INCOMPLETE SUBMITTALS WILL NOT BE ACCEPTED. ALL PLANS MUST BE LEGIBLE AND IN INK.
❑ 1. Site plans, 3 or 4 sets, signed by the preparer of the plans. No graph paper!
❑ 2. Complete plans, 3 or 4 sets, signed by the preparer of the plans (No graph paper!) OR
Engineered plans, 3 or 4 sets, with wet signature on plans AND 2 sets of stamped and signed calculations.
❑ 3. Engineered truss details and layouts in duplicate (if required). No faxes!
❑ 4. Energy compliance design and supporting documentation in duplicate.
❑ 5. Statement of Intent for Non -heated and A/C for Non -Residential Buildings.
❑ 6. Manufactured homes: (A) installation inst, (B) Marriage line info, (C) Floor Plan, (D) Tie down or fnd plans, all in
duplicate.
❑ 7. Metal bldgs: (A) Metal Bldg Plans, (B) Fnd plans and calcs in triplicate, (C) Elevations in triplicate. (D) Floor
plans in triplicate. All of these must be stamped and wet -signed by the engineer.
❑ 8. Flood Elevation Certificate, wet -stamped and signed, in duplicate (if required).
❑ 9. Site plan and business license approval from the City of Biggs.
❑ 10. Letter of intent for non-residential buildings.
❑ 11. Detached Accessory Building Form filled out by the owner (if required).
❑ 12. Hazardous Material Form (for Commercial Buildings only).
Remaining items needed to issue the permit. Additional items may be required after Plan Check and Planning
review (May
require additional plan review upon receipt of the following items.)
❑
1.
Agricultural Buffer clearance and site plan approval from the Ag Commissioner's office (if required).
❑
2.
Impact Fees.
❑
3.
California Department of Forestry plan approval (if required).
❑
4.
NPDES Form.
❑
5.
Encroachment Permit for driveway from the Public Works Dept. (construction approval prior to occupancy).
❑
6.
Contractor's license information. (Number, Name Style, Classification).
❑
7.
Worker's Compensation Carrier and Policy Number.
❑
8.
Owner -Builder Verification (if required).
❑
9.
Letter of Signature authorization (if required).
❑
10.
Recorded copy of Agricultural Acknowledgment Statement.
❑
11.
❑ Grant Deed, ❑ M.H. Title/Statement of Facts.
❑
12.
Sanitation and site plan approval from the Environmental Health Department.
If you have questions or would like additional information regarding this process, please contact a
Permit Assistant at (530)538-7541.
EXPIRATION OF APPLICATION
Applications for which a permit has not been issued will expire one year after date of application. In order to renew action
on an application after expiration, a new application, plans and fees will be required.
REQUEST FOR FEE REFUNDS
Refunds can only be made upon written request by the person who paid the fee. The request must be made within two
years from the date of fee payment on permits not issued, and two years from the date of permit issuance for permits
issued; however, on issued permits refunds can only be made if no construction work has been done. Filing fees, plan
check fees for work plan checked and other department costs are not refundable.
OVER FOR BUILDING PERMIT APPLICATION
KAFORMS\BUILDING F0RMS\B1dgApp1SubRgmts.doc Page 2 of 2 REV 2-24-05
NOTES RESIDENTIAL
PERMIT NO.
007007 05-1719
STURGIS, CHARLES
1069 E EATON RD, CHICO
Cont: OWNER
j RE -ROOF
_ 9
SPECIAL CONDITIONS
CHECKED
BY
SRA
FLOOD CERTIFICATE REQ.
FIRE SPRINKLERS REQ.
SPECIAL INSPECTION ITEMS
VERIFY
USE PERMIT CONDITIONS
" SUB -STANDARD HOUSING LETTER
~JOB FINALED (Date)
Signature
J=OK
0 = Not OK
= Not Appricable
= Not Ready
1ESIDENTIAL (Single & Duplex)
Date UNDERFLOOR (Plans) OK except #'s
1. Zoning -Setbacks -Easements -Flood -Slope
2. Ftg., Main; Soils-Elec. Gmd.-/ P' Fig. Depth
3. Ftg., Garage; Soils-Steel-Elec. Grnd.-/ /" Fig. Depth
4. Ftg., Porches & Decks; Soils -Steel-/ P' Ftg. Depth
S. Stemwalis, Main; Steel-Blockouts-Wrapped
6. Stemwalls, Garage; Steel-Blockouts-Wrapped
6a. Hold Downs and Special Anchors
7. Slab, Steel -Wrapped
8. Piers -Fireplace Ftg.-Steel
9. D.W.V.; Fall-Frtting-Test-2 Way C/O -Sewer Test
10. UF, Gas Pipe; Size Anchors -Yard Gas Piping; Size Test
11. Water Pipe; Test -Anchors -Regulator -Service Test
12. Electric Underground
13. Plenums & Ducts; Clearance -Material -Support -Ins.
14. Girders -Sills -Anchor Bolts-Joists-Vents-Crippies
15. Access & Ventilation
16. Insulation
Date Card B-1 Date Card B-1
Date Card B-1 Date Card 6-1
Date PLUMBING (Permit) OK except #'s
17. Water Htr.; Vent -Access -Combustion Air Baffle
18. Water Pipe; Test & Anchor -Nail Protection
19. D.W.V.; Test Fittings & Anchor -Nail Protection
20. Shower Pan; Test, First Floor -Tub Access
21. Test Tub & Shower, Second Floor -Tub Access
22. Gas Pipe; Sixe & Anchors
23. Fire Sprinkler, Test
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
ELECTRICAL (Permit) OK except #'s
24. Fixture & Transformer Clearance -Ins. Protection
25. Elec. Receptacles Spacing -Lights & Switches at Doors
26. Size Boxes & No. of Conductors Stapled
27. Romex Installed Close to Edge of Studs & C.J.
28. Equip. Ground made up w/Mech Fasteners -Bond Gas & Water
29. 2 Appliance Circuits in Kitchen & Conductor Size GFI
30. Subfeed Wire Size/ /ga. Cu or AI-A.C. Wire Size/ /ga Cu or AI
31. Range Circle/ /ga Cu or AI -Oven Circ. / /ga Cu or Al
Insulated Neutral 0 Yes 0 No
32. Service -Riser Conductors & Ground Main Disconnect
33. Equip. Clearances Panels-Motors-Mech. Equip.
34. Clothes Closet Light -Shower Light -Spa Light
35. Smoke Detector
61. Brace Interior/Exterior Wall Panels
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
MECHANICAL (Permit) OK except #'s
Date
36. A.C. Ducts Insulation & Support
Date
37. Vent Fan, Exhaust above insulation
38. Condensate Drain & Overflow, Size & Grade
39. Furnace -Vent Access -Comb. Ait-Return Air Vent 115 Outlet
40. Attic Access & Platform if Furnace in Attic
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
FRAMING (Permit) OK except #'s
41. Sills Proper Materials & Anchors
42. Walls Studs -Nailing Spacing & Braces -Plates -Sound
43. Bearing Walls over Girders & Floor Nailing
44. Draft Stop in Walls (rat proof)
45. Fire Stops, Furred Ceilings -Stairs -Chasers -Tubs
46. Headers & Beams -Size & Bearing
Date
FRAMING (Continued)
47. Hangers -Post Caps -Anchors -Connectors
48. Cling. Joist-Rftr. Ties-Purlin-Roll Brac: Truss-Shting.-Rtng.
49. Fireplace Ties or Type AFlue-Fireplace Throat Clearance
50. Attic Access; Size & Romex Protection -Draft Stop -Ins. Baffles
51. Bdrm. Windows or Exiting Doors -Sill Ht. & Dimensions
52. Garage Fire Protection Framing -RC Channel
53. Property Line Firewall & Openings
54. Ext. Doors -One T -Check Garage 3rd Story, 2 Exits
55. Stairs; Width -Headroom -Rise -Run -Landing -Fire Protection
56. Plywood on Roof Overhang -Attic Vents -Rafter Outriggers
57. Siding -Nailing Veneer
58. Stucco Mesh -Drip Screed -Fd. Vents-Underflr. Access
59. Glazing Area -Glass Protection -Skylights -Plastic
60. Shear Walls; Nailing -Bolts
61. Brace Interior/Exterior Wall Panels
62. Insulation -Walls -Ceilings
63. Infiltration -Walls -Windows
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
FINAL (Plans) OK except #'s
64. Ext. Steps -Door & Sidelight Protection -Landings
65. Smoke Detector
66. Furnace Vents -clearance -Comb, Au -Connector -
In Garage; Above Floor -Ducts -Meth. Protection
67. Bedroom Exiting
68. G.F.I. & Bath Fixtures & Tub Access -Spa
69. Elec. Trim & Subpanel, Breaker Sizes & Labels
70. Stairs & Rails
71. Fireplace or Stove, Clearance -Hearth
72. Elec. Outlets at Wood Panel, Int. & Ext.
73. Kit. Fixt. & Appliance; Ground -Air -Gap -Cooking Clearance
74. Elec. Outlets & Receptacles at Kit. Counter
75. Garage Fire Door, Swing -Landing -Closure
76. A.C. Duct in Garage -Damper
77. Wtr. Htr.; Vents -Clearance -Comb. Air Connector-P.R.V.
in Garage; Above Floor-Mech. Protection
78. Plb.; Elec. & Mech. Equip. Listed for Location
79. Elec. Receptacles in Garage (F.F.I.)-Romex Protection
80. Insulation -Foam -Looked in Attic
81. Guard Rails & Deck Construction -Post Caps
82. Fdn. VBents & Crawl Hole Door Drainage & Wood -Earth
Clearance Looked under Floor 0 Yes
83. Following InsUd/Drive 0 Yes 0 No/Walks 0 Yes 0 No/Planters 0 Yes 0 No
84. Stucco Brown -Finish
85. A.C. Unit Disconnect, Electrical -Plumbing
86. Vents Above Roof, Plbg-Appliance-Fireplace-Clearance to Openings
87. Water Well, Disconnect, Electrical, Plumbing
88. Exterior Elec. Trim, G.F.I. Receptacle -Underground
89. Ventilation Throughout House
90. Glass Protection
91. Corrections from Previous Inspections
92. Gas Test -Meters Tagged, Gas -Electric
93. Water & Sewer Connected -C/O to Grade -HD Approval
94. Energy Compliance Certificate -Other Certificates
95. Address Posted
96. Fre Sprinkler
Date
Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
Comments at Final:
= OK
=Not OK
= NotRy hie MOBILE HOMES
= Not Ready
Date
MOBILE HOME UTILITIES (Plans) OK except #'s
1. Zoning Requirements -Setbacks -Easements
2. Soils; Special MH Support Sketch
3. Sewer, Location -Test -Fall -C/O -Concrete
4. Water; Location -Test -Easement Needed (Sketch)
5. Electricity, Location-Clearances-Gmd-/ /Amp -Concrete
6. Gas; Location -Test -Wrap;-/ /" L'ft.
/ P Nat or/ /" L "ft1 P LPG
7. Well Clearance & Disconnect
8. Utility Clearance
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
MOBILE HOME INSTALLATION (Plans) OK except #'s
1. Zoning Requirements -Setbacks -Easements
2. Footings; Size -Spacing -Marriage Line
3. Gas; MH Test -Demand -Valve -Connector
4. Electricity; MH Test -Crossovers -Breakers -Clearances
5. Drain; MH Test -Fall -Flex Connector
6. Water, MH Test-Regulator-Connectoe
7. Water and Sewer Connected -C/O to Grade -HD Approval
8. Gas and Electricity Tagged
9. Tie Downs -Type -Installation Cert.
10. Exits; Insp.-Sketch
11. Cert of Occupancy
Date Card B-1 Date Card B-1
Date Cana B-1 Date Card B-1
Date PERMANENT END SYSTEM (ONLY)
1. Zoning Requirements -Setbacks -Easements
2. Footings; Size -Spacing -Marriage Line
3. Blocking
4. Gas; MH Test -Demand -Valve
5. Electricity; MH Test
6. Water, MH Test
7. Water and Sewer Connected
8. Gas and Electricity Tagged
9. Exits
10. License Decals
11. Verify #'s with Office
Date Card B-1 Date Card B-1
Date Card B-1 Date Cana B-1
MISCELLANEOUS
Date DECKS, COVERS, CARPORTS, GARAGES (Plans) OK except #'s
1. Zoning Requirements -Setbacks -Easements
2. Footings; Soils -Size -Depth -Spacing -Connectors -Steel
3. Decks, Girders and/or Joists -Decking -Bracing -Stairs -Rails
4. Wood Awn.; Posts-Beams-Rftrs-Connectors
Shthg-Frg-Bracing
5. Alum. Awn.; Columns -Connections -Splice -Decal -Enclosures
6. Carports; Windows -Doors
7. Electric
8. Frmg.; Sills-Anchors-Studs-Rftrs-Trusses
9. Siding; Nailing -Veneer -Stucco -Mesh
10. Roof; Shthg-Roofing
11. Ext.; Steps -Doors -Landings
12. Braced Wall Panels
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
Date POOLS (Plans) OK except #'s
1. Setbacks -Easements
2. Soils; Compaction -Structure Stability
3. Pool Structure; Steel -Connections -Thickness
Dead Men -Lining
4. Elec.; Receptacles and Lighting, Distance -GA
5. Elec.; Pool Lighting; 15 Vofts-GFI
6. Elec.; Enclosures; Conduit Entries -Terminals -Listed
7. Elec.; Bonding; Metal w/5' -Circulating Equip. -Heater
8. Elec.; Grounding; Equip. w/5' Circulating Equip. -Pool Lghtg.
Boxes-Enclosures-Panelboards-Ins. to Main Conduit
9. Health Department Approval
10. Plumb.; Cir. Test -Water Supply Test
11. Light Niche
12. Enclosure; Fencing -Alarms
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541 FAX#: (530)536-2140
WEBSITE: www.buttecounty.netkdds
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of Division 3 of
the Business and Professions Code, and my license is in full force and
effect.
License Class: License Number:
Date: Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the
Contractors' State License Law for the following reason (Sec. 7031.5
Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior
to its issuance; -also requires the applicant for such permit to file a
signed statement that he or she is licensed'pufsuant to.the provisions of
the Contractor's State License Law (Chapter 9 -commencing with Section
7000):of Division 3 of the Business and Professions Code) or that he or
she is exempt therefrom' and the basis for the alleged exemption: Any
violation of Seclion,7031.5 by any applicant for a permit subjects the
applicant to a civil penalty of not more than five hundred dollars ($500).):
I, as owner of the property, or my employees with wages as their
sole compensation, will do the work,, and the structure is not
;jntende:d,or,.of(efed,.for, sale„(Sec..;7Q44,_ Business and Professions
Code: The Contractors' State License Law does not apply to an
owner of property who,;builds or improves thereon, and.who does
such work himself or, herself or, through his or her own. employees,
provided that such improvements, are not intended or offered for
sale. If however, the building or improvements are sold within one
year of completion, the owner -builder will have the burden of
proving that he or she did not build or improve for the purpose of
sale.).
❑ ....I, as.. owner... oL. the<. property,:..am.,: exclusively... contracting .with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code. The Contractors' State License Law does
not apply to an owner of properly who builds or improves thereon,
and who contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
❑ I amxempt under Article %%�the Bd Pro ,yions Code
WORKERS: COMPENSATION DECLARATION V
I hereby affirm under penalty of perjury one of the following declarations:
O 1 have and will maintain a certificate of consent to self -insure for
workers' compensation, as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
❑ 1 have and will maintain workers' compensation insurance, as
required by Section 3700 the Labor Code, for the performance of
the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier:
Policy #:
❑ I certify that in the performance of the work for which this permit is
issued. I shall not employ any person in any manner so as to
become subject to the workers' compensation laws of California.
and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions. .
Date:
Applicant:
WARNING: Failure to secure workers' compensation coverage is
unlawful, and .shall subject an employer to criminal penalties and one
hundred thousand dollars ($100,000), in addition to. the cost of
compensation, damages as provided for in Section 3706 of the Labor
code, interest, and attomey's,fees.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec 3097 Civ.)
Address:
PERMIT NO.
BPO51719
Issued Date: 06/30/2005 APN: 007-150-105-000
Site Address: 1069 E EATON RD CHI
Map Index:
Description: RE -ROOF (14)
Owner: STURGIS CHARLES EDWIN ~'
1069 EATON RD
CHICO, CA
95973-9131
Applicant: STURGIS CHARLES. E_D•WIN
1069 EATON RD
CHICO, CA
95973-9131
Contractor:
License #:
Architect:
Engineer:
Total Square Ft:
Valuation:
.Census Code:
0i
0 S. F.
$0.00
(D. 00
6
X312 Gi
iereby issued
do work Indic
PERMIT EXPIRES
�,1111111`m
icable provisions of the Buffe County c:oor+ ?nrvor
which fees have been paid.
r
IA.__ Date: _
❑ 1 hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage,
handling and use of hazardous materials. -
❑ Notification in accordance with Section 19627.5 of California Health & Safety Code is not applicable to the scheduled construction of this project.
O Attached are copies of the required E.P.A. notification forms.
I hereby certify that I have read this application, that the above information is correct, and that I am the owner or the duly authorized agent of the ner. I agree to comply with
all county and state laws relating to building construction. I acknowledge.it is unlawful to alter the substanc y official form or dogiment of It County. I hereby
authorize representatives of Butte County to enter upon the above mentioned property for inspection pu
Print Name:
�nl rri� �� �t< �Q (Q [ Signature
Date:
• �
❑ Contractor LI Agent for Owner ❑ Agent for Contractor
wner