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Home My WebLink About021-134-014. — . a .• — ._ t• _ ' • . - _ — _` _ _ — .- • - ♦�.1 - 4 a-`. ___- _ . KLZ,- 7..0.1*r4a•�n1c., eIns'', �r 9r7-1248")V�"Err---- —WRIGHT, WRI GHTz02111.3 4" -Joe -,--__—, 26z,-69 B-MELFNDEZ, ;. - _ _ . �1272�B16ckfR6ad; zGridley�,.,r�� 4 �-2521 _ (el"ec up`g'r`ade)SF,No:Valley,Elec233-6 Pu:d Baa ,9191� e/s Block Rd, app. 9001 no. -of W. Li-erty Rd. �r Gridley (new single family) %'11Jp7L, . ` - is ' '•� - - • 1 rKj a i e t 021-131-4-014 - 97-1248'E, _ MELENDEZ, , Frances. ` 1272 Block Road, Gridley (elec upgrade)SF*No. Valley Ele r 1 r i r 1 r (Rev. 9 2/96) COUNTYOF BUTTE -DEPARTMENT OF DEVELOPMENT SERVICES- BUILDING DIVISION 7 County Center Drive - Oroville, balifornia 95965 - Telephone (916) 538-7541 PERMIT NO. w. APPLICATION AND PERMIT --/�—, / :z ASSESSOR PARCEL NUMBER 021-134-014 ZONING BUILDING PERMIT OWNER FRANCES MFIYMEZ TELEPHONE SQ. FT. OCC. BUILDING VALUATION OWNERS MAILING ADDRESS 1272 BLOCK RD GRIDLEY CONTRACTOR'S NAME NORTH VALLEY ELECTRIC TELEPHONE CONTRACTOR'S MAILING ADDRESS CONSTRUCTION LENDER LENDER'S MAILING ADDRESS Fireplace Total Valuation $ ARCHITECT OR ENGINEER LICENSE NO. Filing Fee $ 20.00 Permit Fee $ ARCHITECT OR ENGINEERS MAILING ADDRESS Plan Checki6 Fee $ BUILDING ADDRESS 1272 BLOCK RD Energy Plan Checking Fee $ GRIDLEY PERMIT FEE $ LOT NO. SUBDIVISIONS NAME PARCEL MAP PLUMBING PERMIT Filing Fee 20.00 USEOFSTRUCTURE SF ❑ Duplex ❑ Mobilehome ❑ Other ' SPECIFY Each Trap 7.00 Solar or heat pump water heater 23.00 Water piping 15.00 Each gas water heater or vent 15.00 TYPE OF WORK New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other ❑ ELECTRIC UPGRADE Describe Work: Gas piping system 1- 5 outlets 15.00 Building sewer 15.00 Mobile Home I S I G I W @20.00 PERMIT FEE $ ELECTRICAL PERMIT Filing Fee 20.00 600V OR LES Main Service 200" OR LESS 23.00 23.00 LICENSED CONTRACTOR'S 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 i full force and effect. q License Class — Llc. NO. OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason: ❑ I, as owner of the property, or my employees with wages as their sole compensation, 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 to construct the project. ❑ 1 am exempt under Sec. Business and Professions Code for this reason Main Service 200A TO I000A 46.00 NEW CONST. DWELLING OCCUP. OR ADDNS. ( a ACC. BLDS. SO 3.50FT. NEW CONST - NON -RES D: MUITI.OUTuTS LET @7,50 POWER APPARATUS b SINGLE OUTLET CIS. EX. OCCU OUTLET OR FIXTURES 20 @ I'00 BAL @ .50 Ex. Occup. OUTLETS RES D.oEA 5.00 Temporary Service 23.00 Mobile Home Facilities 20.00 Misc. Wirina 23.00 3. 00 PRE INSPECT 123—W PERMIT FEE $ ou ` WORKERS' COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I, 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 of the Labor Code, for the performance of work for which this permit is issued. My workers' compens$ti�ce .�r�rgd poli n tuber are: Carrier % tom` V u Y Policy Number 1 Z (The above sections need not'be completed if the permit is for work of a valuation of one hundred dollars ($100) or less.) ❑ 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 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 forthw(th comply with thoseNpcovisions. %%�� / X _�af/1./ez �+"'�' Date r7 "^ �Z Signature of Applicant -_❑ Owner ❑ Contractor ❑ Agent An OSHA permit is required for excavations over 60" deep and demolition or construction�y1 of structures over 3 stories in height. MECHANICAL PERMIT Filing Fee 20.00 Heating Cooling Hood 6.50 Ventilation PERMIT FEE $ Mobile Home Installation Fee $ Energy Inspection Fee $ OCC CONST. TYPE TOTAL FEE $ 89,00 HAZ. D. FEES IMP I FLOOD CDF PARCEL PD HD I ISSUE le This permit is hereby issued under of the Butte County Code and/or indicated above for which fees have orf �,,� _, By _—T "�'r"` / PERMIT EXPIRES ON the applicable provisions Resolutions to do work been paid. Date / / (Data)' Receipt No. 222415- I WHITE-D.D.S.-B.D. CANARY -ASSESSOR PINK -INSPECTOR GOLDENROD -APPLICANT � .��y:*rrFi 3 :l'''s 1 �1`:'�,.:•i,;��.t:,y ,e'r,/�i Y/r_ :-s d � ' � . i.�S COUNTY OF BUTTE/ BUILDING DIVISION DEPARTMENT OF. DEVELOPMENT.SERVICES 1469 Humboldt Road, Chico, CA -t(916) 891-2751 7 County Center Drive, Oroville, CA _ (916)`538-7541 .1747 Elliott Road, Paradise, CA - (916) 872-6307 CORRECTION NOTICE PERMIT NO. A routine inspection ' icates that the following violations of Butte County Ordinances exist at the above addres nd should be corrected. Please notify this office when correction of work is completed. l ou have any questions pertaining to this matter, or need additional explanation, please cont t this office immediately. t - s< �a Fd; ' fi. i:. Ci.• Date :f q7 Inspector K1,456al 6,1 REV 10/92 COUNTY OF BUTTE BUILDING DIVISION DEPARTMENT OF DEVELOPMENT SERVICES 1469 Humboldt Road, Chico_ CA - (916),891-2751 7 County Center Drive—Oroville, CA -a]@ 538-7541 747 Elliott Road, Paradise,tA - (916) 872-6307 CORRECTION NOTICE 9'7�� OWNIfIR'-r—� g4- PERMIT W— A routine inspection indicates that the following violations of Butte County Ordinances exist at the above adXddres nd h uld be corrected. Please notify Asp. when correction of work f is completed. If hav: O.y questions pertaining to this matter, or need additional explanation, t t u his ont t this ffi mediately. pleas�e ycont; N? 9 &4A LI A N. COUNTY OF BUTTE- DEPARTMENT OF DEVELOPMENT SERVICES - BUILDING DIVISION 7 County Center Drive - Oroville, California 95965 - Telephone (916) 538-754J, I�PEERM T (Rev. 12/96) APPLICATION AND PERMIT ASSESSOR PARCEL NUMBER 021-134-014 ' ZONING BUILDING PERMIT O OWNER FRANCES MELENDEZ TELEPHONE SO. FT. OCC. BUILDING VALUATION OWNERS MAILING ADDRESS 1272 BLOCK RD GRIDLEY CONTRACTOR'S NAME NORTH VALLEY ELECTRIC TELEPHONE ' CONTRACTORS MAILING ADDRESS CONSTRUCTION LENDER LENDER'S MAIUNG ADDRESS Fireplace Total Valuation $ ARCHITECT OR ENGINEER LICENSE NO. Filing Fee $ 20.00 Permit Fee $ ARCHITECT OR ENGINEERS MAILING ADDRESS Plan Checking Fee $ BUILDING ADDRESS 1272 BLOCK RD Energy Plan Checking Fee $ GRIDLEY $ PERMIT FEE $ LOT NO. SUBDIVISION'S NAME PARCEL MAP PLUMBING PERMIT Fling Fee 20.00 USEOFSTRUCTURE SF ❑ Duplex ❑ Mobilehome ❑ Other SPECIFY Each Trap 7.00 Solar or heat pump water heater 2 3. 00 Water piping 15.00 Each as water heater or vent 15.00 TYPE OF WORK New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other ❑ Describe Work: ELECTRIC UPGRADE Gas piping system 1 - 5 outlets 15.00 Building sewer 15.00 Mobile Home I S I G I W @20.00 PERMIT FEE $ ELECTRICAL PERMIT Fling Fee 20.00 Main Service 200A OR LESS 23.00 2 3.00 LICENSED CONTRACTOR'S 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 ISI full f0 andeffect. yrn/� License CIBss — Lic. No. �`J (/J J(J `J OWNER -BUILDER DECLARE 1 hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason: ❑ 1, as owner of the property, or my employees with wages as their sole compensation, 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 to construct the project. ❑ 1 am exempt under Sec. Business and Professions Code for this reason Main Service 200A TO 1000A 46.00 NEW CONST. DWELLING OCCUP. OR ADONS. ( 8 ACC. BLDS. so 3.52FT. NEW S. NON•RESIIDT M.0jCl OUTLET 97.50 POWER APPARATUS SINGLE OUTLET CIR. Ex. Occup. . OUTLET OR FIXTURE �L @ lap Ex. Occu .O""ED R oom 5.00 Temporary Service 23.00 Mobile Home Facilities 20.00 Misc. Wirina 23.00 23.00 PRE INSPECT 23.00 PERMIT FEE = 89.00 WORKERS' COMPENSATION DECLARATION 1 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 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 of the Labor Code, for the performance of work for w is this permit is issued. My workers' coce rr' r p nf5 ber are: Carrier 1/(�� (Jli / MECHANICAL PERMIT Filing Fee 20.00 Heating Cooling Hood 6.50 Ventilation PERMIT FEE $ Policy Number (The above sections need not be clompleted if the permit is for work of a valuation of one hundred dollars ($100) or less.) ❑ 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 workers' compensation laws of California, and agree that if I should become subject to the worker compensation rovis' s of section 3700 of the Labor Code, I shall ' forth,#ftcomply with t o e Isions. Date 6_,6—�z „__ Sign re of Applicant - ❑ Owner ❑ Contractor ❑ Agent An OSHA permit is required for excavations over 60" deep and demolition or construction of structures over 3 stories in height. Mobile Home Installation Fee $ Energy Inspection Fee $ occ CONST. TYPE TOTAL FEE $ 89.00 HAZ. D. FEE IMP I FLOOD I CDF PARCEL PD -71 ISSUE This permit is hereby issued under the applicable provisions of the Butte County Code and/or Resolutions to do work indicated above for which fees have been paid. By ;te _ PERMIT EXPIRES ON Deta Receipt No. 999415 WHITE-D.D.S.-B.D. CANARY -ASSESSOR PINK -INSPECTOR GOLDENROD.APPLICANT (Rev. 12/96) COUNTY OF BUTTE- DEPARTMENT OF DEVELOPMENT SERVICES -BUILDING DIVISION 7 County Center Drive - Oroville, California 95965 - Telephone (916) 538-7541 APPLICATION AND PERMIT PERMIT NO. ASSESSOR PARCEL NUMBER ZONING BUILDING PERMIT NV � /-�// I 3 / /�--2/ TELEPHONE SO. FT. OCC. BUILDING VALUATION OWN MAILING ADDRESSoel/ G� ti CONT7. 'S NAME o r L/ c r ELEPHONE ' CONTRACTORS MAILING ADDRESS CONSTRUCTION LENDER Fireplace LENDER'S MAILING ADDRESS Total Valuation $ ARCHITECT OR ENGINEER LICENSE NO. Filing Fee $ 20.00 Permit Fee $ ARCHITECT OR ENGINEERS MAILING ADDRESS Plan Checking Fee $ BUILDING ADDRESS / /� J d C_ / Energy Plan Checking Fee $ $ V PERMIT FEE S LOTNO. SUBDIVISIONS NAME PARCEL MAP PLUMBING PERMIT Filing Fee 20.00 USEOFSTRUCTURE SF Q' Duplex ❑ Mobilehome ❑ Other (` SPECIFY Each Trap 7.00 Solar or heat pump water heater 23.00 Water piping 15.00 Each as water heater or vent 15.00 TYPE OF WORK New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other Describe Work: r ; c_ 11(d0 Gas piping system 1 - 5 outlets 15.00 Building sewer 15.00 Mobile Home IS I GI W1 920.00 PERMIT FEE $ ELECTRICAL PERMIT Fling Fee 20.00 Main Service zo.A600V OR LESS 23.00 D LICENSED CONTRACTOR'S 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 Lic. No. OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason: ❑ I, as owner of the property, or my employees with wages as their sole compensation, 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 to construct the project. ❑ 1 am exempt under Sec. Business and Professions Code for this reason WORKERS' COMPENSATION DECLARATION WORKERS' 1 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 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 of the Labor Code, for the performance of work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy Number (The above sections need not be completed if the permit is for work of a valuation of one hundred dollars ($100) or less.) ❑ 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 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. X Date Signature of Applicant - ❑ Owner ❑ Contractor ❑ Agent An OSHA permit is required for excavations over 60" deep and demolition or construction of structures over 3 stories in height. Main Service 200A TO 1000A 46.00 NEW CONST. DWELLING OCCUP. so OR ADONS. ( 6 ACC. BLOS. 3.5¢FT, NEW CONST. MULTI.OUTIET NON-RESID. @7.50 POWER APPARATUS d SINGLE OUTLET 1: SIR. � � ,.o, Ex. OCCU OUTLET OR FIXTURES BAL so Ex. Occup. ourLEETS .a.OEA 5.00 Temporary Service 23.00 Mobile Home Facilities 20.00 Misc. Wirin 23.00 / - ) h S D PERMIT FEE 9q.0 MECHANICAL PERMIT Fling Fee 20.00 Heating Cooling Hood 6.50 Ventilation PERMIT FEE S Mobile Home Installation Fee Is Energy Inspection Fee is occ CONST. TYPE TOTAL FEE $ �9. o� HAz. o. FEES IMP FLOOD I CDF PARCEL PD 1 HD ISSUE This permit is hereby issued under of the Butte County Code and/or indicated above for which fees have By EXPIRES ON the applicable provisions Resolutions to do work been paid. Date Da fa ReceiptNo.PERMIT WHITE-D.D.S.-B.D. CANA -A SESSOR PINK -INSPECTOR GOLDENROD -APPLICANT COUNTY OF BUTTE- DEPARTMENT OF Dg7ELOPMENT SERVICES -BUILDING DIVISION 7 COUNTY CENTER DRIVE - OROVILLE, CALIFORNIA 95965 - TELEPHONE (916) 538-7541 PERMITAPPLICATION DATA SHEET OWNER: ArOACCA/f yl ASSESSOR PARCEL ER: / , 13 �} Proposed Building Use: Building Inspector: Date: At time of permit application, I was advised the following data must be submitted prior to permit processing and/or issuance: Date Received By 111. All items have been submitted -------------------------------------------------------------------------------------- E12. Plot plans, 3/4 sets, signed by the preparer of plans. ------------------------------------------------------------ ❑3. Complete plans, 3/4 sets, signed by the preparer of plans. ----------------------------------------------------- ❑4. Engineered plans, 3/4 sets, with wet signature on plans. All engineering must be shown on plans. -------- ❑ 5. Engineered truss details and layout in duplicate (required prior to plan review) No faxes! ------------------ ❑ 6. Energy Design Compliance and supporting documentation. ---------------------------------------------------- ❑ 7. Statement of Intent for Non -Heated and A/C Buildings. --------------------------------------------------------- ❑ 8. Hazardous Material Form. ------------------------------------------------------------------------------------------ ❑9. Manufactured Home data and installation instructions including Tie Down Specifications ------------------- 0 10. Fees of $ ------------------------------------------------------------------------------------- ❑ 11. Impact fees as shown on the attached schedule. -------------------------------------a--------------------------- ❑ 12. California Department of Forestry plan approval/fees. --------------------------------------------------------- ❑ 13. Flood elevation certificate. ---------------------------------------------------------------------------------------- ❑ 14. Sanitation and plot plan approval Health Department. ------------------------------------------- ❑ 15. City of Chico plumbing permit. ----------------------------------------------------------------------------------- ❑ 16. Plot plan and business license approval from the City of Biggs. ---------------------------------------------- ❑ 17. Planning approval for (A) Use: (B) Parking: -------------------------- E1.1 8. ------------------------- ❑18. Contact Land Development about ❑ Improvements, ❑ Drainage, ❑ Legal Parcel. ----------------------- croachment Permit for dnriv/eway constructs approval prior to occupancy). ---------------------------- E111 �9,�fi0. Pre -inspection for G (c- c I r C required. Request to Building Inspector on (Date) ❑21. Contractor's license information. (Number, Name Style, Classification). ---------- El 22. Workers' Compensation carrier and policy number. ----------------------------------------------------------- ❑23. Owner -Builder Verification (Given to owner ❑, Mailed to owner 0) - -------------------------------------- ❑24. Letter of signature authorization. -------------------------------------------------------------------------------- ❑25. Recorded copy of Agricultural Acknowledgment Statement. -------------------------------------------------- 026. Letter of intent on building use. ----------------------------------------------------------------------------------- ❑27. Manufactured Home utility clearance. --------------------------------------------------------------------------- ❑28. Existing violations and/or expired permits. ---------------------------------------------------------------------- ❑29. 043 A, ❑Grant Deed, ❑ M.H. Title, ❑ Check to H.C.D $ .--------------- 030. -------------- ❑30. Other: ------- .When you issue the permit, process as follows ❑ Mail to owner, ail to cgactor. �s�S1Telephone � V ' r and hold for pickup at UK �% r/!/ ?.E1 Delivef�vi Spector. App 'can . - Date: Copy of Haz-Mat form sent ❑ Health Department, ❑ Fire Department, ❑ ' PollutioDate: By: Copy of plans sent ❑ Health Department, ❑ Fire Department, ❑ Other: Date: By: Index permit application for the above items numbered: 2. Additional items required: ❑ Plan Check List Contractor, designer, owner, was advised of the above required data by ❑ phone, ❑ mail, ❑ Building Division counter, by Date: Contractor, designer, owner, was advised of the above required data by ❑ phone, ❑ mail, ❑ Building Division counter, by Date: Contractor, designer, owner, was advised of the above required data by ❑ phone, ❑ mail, ❑ Building Division counter, by Date: Contractor, designer, owner, was advised of the above required data by ❑ phone, ❑ mail, ❑ Building Division counter, by Date: Plans reviewed by: Date: Plans approved by: Date: Sets of plans on hold in ❑ Plan Cabinet, ❑ A.P. folder. Note transfer by: Date: Yellow Copy - Department of Development Services, Building Division. t LOCATION: DATE: l �° AP.#: CONTRACTOR PRE -INSPECTION FOR DATE TO INSPECTOR ERMTT HISTORY [ ]NONE MAS FOLLOWS: - P j. TYPE OF OCCUPANCY: BUILDING INSPECTOW S REPORT ng Description: [ ] C mmercial/Usage: e sidential/# of Units: Mobile Home: Yes[ J No [ ] Currently Occupied. [. ] Abandoned/Vacant. tx . ices [ ] No f Electric is currently : [ ] On [ ] .Off Condition of electrical? Natural Propane[ ] None[ # ] Currently On[ ] Off[ ] i... Obvious problems: ation: Plumbing working Yes[ No[ Well: Yes[ ] No[ ] Potable water: Yes[ ] No(- ] Obvious Sewage Pr71e, n Recommended: [ ]Hold for: r Date: L COUNTY OF BUTTE - DEPARTMENT OF DEVELOPMENT SERVICES - 7 County Center Drive - Oroville, Czlifornia 95965 - Telephone (Rev. 12/96) APPLICATION AND PERMIT BUILDING DIVISION (916) 538-7541 PERMIT NO. ASSESSOR PARCEL NUMBER ZONING BUILDING PERMIT a�-/,3-2/- 4 TELEPHONE SO. FT. OCC. BUILDING VALUATION OWN�s LWUNG ADDRESS ,�/ % j,� 12 3L OC / /' Cl 0 & /1 C 011 t Z . CONTRACTOR'S NAME / f ELEPHONE CONTRACTORS MAJUNG ADDRESS CONSTRUCTION LENDER Fireplace LENDER'S MAILING ADDRESS ' Total Valuation is ARCHITECT OR ENGINEER LICENSE NO. Filing Fee $ 20.00 Permit Fee $ ARCHITECT OR ENGINEERS MAKING ADDRESS Plan Checking Fee $ BUILDING ADDRESS h Energy Plan Checking Fee $ G / , c F PERMIT FEE $ LOT NO. suaomSIONS NAME PARCEL MAP. PLUMBING PERMIT Fling Fee 20.00 Each Trap 7.00 USEOFSTRUCTURE SF i� Duplex ❑ Mobilehome ❑ Other /` SPECIFY Solar or heat pump water heater 23.00 Water piping 15.00 Each gas water heater or vent 15.00 TYPE OF WORK New ❑ Addition ❑ Remodel ❑ /Udlides ❑ Installation ❑ Other' Describe Work: l Ci c f r 1 C A/ G /�C'�� Gas piping system 1 - 5 outlets 15.00 Building sewer 15.00 Mobile Home ISI GI W @20.00 PERMIT FEE $ ELECTRICAL PERMIT Filing Fee 20.00 800V OR LESS Main Service p A OR LESS 23.00 (rjC LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing vrkh Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect License Class Lic. No. OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason: ❑ I, as owner of the property, or my employees with wages as their sole compensation, 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 to construct the project. O 1 am exempt under Sec. Business and Professions Code for this reason WORKERS' COMPENSATION DECLARATION 1 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 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 of the Labor Code, for the performance of work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy Number (The above sections need not be completed if the permit is for work of a valuation of one hundred dollars ($100) or less.) ❑ 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 workers' compensation laws of California, and agree that H 1 should become subject to the workers' compensation provisions of section 3700 of the Labor Code, I shall forthwith comply with those provisions. X Date Signature of Applicant - ❑ Owner ❑ Contractor ❑ Agent An OSHA permit is required for excavations over 5'0• deep and demolition or construction of structures over 3 stories In height. Mein Service sow TO 1000A 46. NEW CONST. DWELLING OCCUCCUP. so SO OR ADONS. ( & ACC. BLDS. 3.50M ,N,OI+RESID. EmAwMUITFOIRCUT La7.50 POW APPARATUS a SINGLE OUTLET CIR. Ex. Occup. OUTLET OR FOnURES 8* O '.SO FIKEO APP US. OR Ex. Occup. ouTLETs RESID. EA. 5.00 Temporary Service 23.00 Mobile Home Facilities 20.00 _. Misc. Wirin x .i +_�23.00 - ) h S _ PERMIT FEE $ MECHANICAL PERMIT Fling Fee 20.00 Heating Cooling Hood 6.50 Ventilation PERMIT FES $ Mobile Home Installation Fee $ Energy Inspection Fee $ occ CONST. nvE TOTAL FEE $ �9. OC) KAZ o. FEES IMP FLOOD CDF PARCEL Po HO UE This permit Is hereby Issued under the applicable of the Butte County Code and/or Resolutions Indicated above for which fees have been By Date PERMIT EXPIRES ON provisions to do work paid. To Receipt No. WHITE •D.D.S.•B.D. CANARY -ASSESSOR PINK -INSPECTOR GOLDENROO•APPLICANT