HomeMy WebLinkAbout022-340-007` ~
'
'-022-340-007 04-1032 356-72P
AR SSo C3 11-7 LL ID
3 8-72
'
440 JUSTtSON RD, GRID
Cont: E
' --- ' ----------_-
#Is Justeson Ave. 6001. w. ot" W---biggS-Gridley21'-
STUCCO HOUSE(I 820) Gridley
02 -340-007 (new single family) Y"'.."-�
06-2107
PETER, CHARLES & KIM
Cont: SPENCER INC.
H HVAC
17]
P D 7G
022-34d 007
PETER,, CHARLES & KIM
440 JUSTESON RD, GRIDLEY
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022340007
--a 6 �
E. "' 06-2107 ✓{"
• PETER, CHARLES & KIM%,r,.t �,. ) f-
440 JUS TESON RD, ' RI bLEY ff
NOTES • Con SPENCER INC"�'
HVAC
RESIDENTIAL
' AM Permit Na "
Owner.
Site Address:
Contractor.
Type of Permit:
t
R,
•• r
SPECIAL COMMONS
CHECKED BY
Q SRA
Q FLOOD CERTffICAT'E EQUIRED
Q FIRE SPRINKLERS REQUIRED T
Q SPECIAL INSPECTION ITEMS
QVERIFY
Q USE PERMfT CONDITIONS
Q SUBSTANDARD HOUSING LETTER
Q ENCROACHMENT PERMIT
Q REINSPECTION FEE PAID
Q ENV HLTH CLEARANCE
a
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.netWds
PERMIT NO.
BP062107
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: 08/31/2006 APN: 022-340-007-000
the Business and Professions Code, and my license is in full force and
effect.
*0—
License Class:License Num
Site Address: 440 JUSTESON RD GRI
Date: Contractor.
Map Index:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the
Description: HVAC CHANGE OUT
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
Owner: PETER, CHARLES & KIM
to Its issuance, also requires the applicant for such permit to file -a
440 JUSTESON ROAD
signed statement that he or she is licensed pursuant to the provisions of
the Contractor's Slate License Law (Chapter 9 commencing with Section
GRIDLEY, CA
7000) of Division 3 of the Business and Professions Code) or that he or
95948
she is exempt therefrom and the basis for the alleged exemption. Any
violation of Section 7031.5 by any applicant for a permit subjects the
applicant to a civil penalty of not more than five hundred dollars ($500).):,
O 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 (Sec. 7044, Business and Professions
Applicant: SPENCER INC., R.B.
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,
1188 HASSETT AVENUE
provided that such improvements are not intended or offered for
sale. If however, the building or Improvements are sold within one
YUBA CITY, CA 95993
year of completion, the owner -builder will have the burden of
530-674-8307
proving that he or she did not build or improve for the purpose of
sale.).
❑ 'I, as owner of 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 property who builds or improves thereon,
Contractor: SPENCER INC., R.B.
and who contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
1188 HASSETT AVENUE
❑ I am Exempt under Article 3 of the Business and Professions Code
YUBA CITY, CA 95993'
530-674-8307
Date: Owner:
License #: 664429
WORKERS' 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
Labor Code, for the performance of the work for which this permit
Architect:
is issued.
have
'IrI have and will maintain workers' compensation insurance, as
Engineer:
by Section 3700 the Labor Code, for the performance of
the work for which this permit is issued. My workers' compensation
insurance carrier anal policy number are:
Carrier:
Total Square Ft: 0 S. F.
c� ��
Policy #:
Valuation: $0.00
❑ I certify that in the performance of the work for which this permit is
Census Code:
issued, I shall not employ any persons any manner to
become subject to the workers' compensation laws of California.l r
L.I�.o-•,�
q-(0
and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply wi h those provisions.
Date.
\�
S J V
Appli
WARNING: Failure to secure workers' co em ation coverage is
unlawful, and shall subject an employer to cr' inal 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 attorney's fees.
CONSTRUCTION- LENDING AGENC`! , -
I hereby affirm that there is a construction lending agency for the .
'This permit is hereby Issued under the applicable provisions of the Butte Cnunty Code a rV r
Resolutio t do work Iri I "ted e f which fees have been paid.
performance of the work for which this permit Is issued (Sec 3097 Civ.)
/_
Name:
r e
B Date: w
PERMIT EXPIRES ON: -167
ate
Address:
❑ 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.
O Notification in accordance with Section 19827.5 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 t duly authorized agent of the owner. I agree to comply with
all co�rnty and state ws relating to building construction. I acknowledge It is unlawful to alter I ubstance ol. a lel loan or document of Butte County. I hereby
41ives
authorize repro Co
of Butte Co my enter Upon a above mentioned property for inspe tion.purposos
Print Name: M4�� Signet
�L
Date:
0 Owner ❑ 'Contractor 0 Agent for Owner Agent for Contractor
t
tkiRtIFI'C' 'A"'TE,0#'F[ELD', N'& t)[Ai G'N0S7T[C",. T'ES T -IN G. -j 0 age Vof 8) CF4R .
Proj mt Add mm
440 Jus_te_soii_Rd_959PWA
B 4ildvNam,,
,1
-B'uil&r C&U& 'LFnnska_1_1i_r_j_C
g - 6 _nt r —ac t
R.B. Spencer Incl
7eAepb6ne:',
Plan Number
-HERS Rater __
Home_E�a_la�y_sj
'Teleob6ne'
76&�6_873_22_81
Sam*:Gio4p Number
,2
Co '1 isncz Method (Premri#i v6)'CI
-
11 A'Y%
i msteZon'e 1111
,Certi fyi ng,Signature:
iec_&6_ _s7 n
70 Wc�iKy ig ed) 1
09/131061 Dai
Sample H6us&N'
33427
Firm
ffn_i_1a_sys_1ffor_p_]
A LTERAt,70N$'! .' DU . a SysteT41U""s HVAC E4u'iprr*iut Clizuje-Oih
HEMP ro4ider.
tBP7CA
Street,Addrew':
25_0�C_a_m_6`illo_Ave_1
E ntr Tested Leshage P bkw,i n*CMErom CTL6R:. Pr�-Test of EA i 7 t i n' g. I 5'u'd .3 rior 16
Dud System 'Ak&ation:a'nd'/-&rEtqtLipme4itCha ng:er 0 1 ut.
talexic—o-CA-92231.1
"pleS TO:, t.5 Ul WER7 nLm rKuv kVEK AN IV, 15 U1 UVII NUD.UFARIMENT
149R'S RATtlk Lb kPL[�kW 9 9H
TAT , ENT
0 -TcsLcd 1/ 0ARm v6dOAosafnplefinLl Lhouae "
od
F�. b L, W'aa".
As-AheHERS raw provid ' in,&'.diagnwti,-twtiniandf0d%mrifi6ton'lb--nify: site
tbebagnostr, testa c-o7l pqu� requi reir�enis as cbmked st'on:o'is. Lrm. ne HERS- rat&, must cbe,�k a nd.veii,fy-'Ak tbe new
distribution system is ful y durned and. corrmt tape is used bef6re:a,CPL4R'm-Ay1 be"relessedon every tested building TbeHERS
wp_,
rater 6usi, not reletbstPL4R,'Until 66mplel.Mand signed CF-6R_basbe.6n
b
�The instiller bsg'roopy of CP -.6R (I neti I laticw Certi fie*).,
NewDiFtribat ' a fu�l 1�' clow- not use tu�il.di ng: cavitiee! I as 151 enurwor 'Isiform returns in,k.,.ofduct
New'p
:SYSL'0TM rubber ad FesJvc ducl Lape 1od,'rniiii c,.aTid 'J
draw bands,imusod in
combination ,with clo(h bgakcd; `iubbcr`adh-wi'yA=1 L*, to ecaf 1eaUat'dw-L" om n=6"'
ons.
'al,, d0](6bjdiptvwf&Kv ae &�aJzB4'ipt RA CW'ApfieAlix R C4.3.
Duel Djagnbe icCcakaRcTeshng, Rw ul-1.91
NEW
COMSTRUMON!
'DuctPressur i2stion -Test Resuiw.('CF'M'@"M Pa')
M6sured
valves,
I
'Eniv-7peted teshkge F loltiel i n' , CW -
,2
ibn -P l6kc-CalculateA (Nomi na l-, V O'Cool i ng � O'Heati ng) o r V O.Measlure;d
Mniean ow'
r,toiaFP �' PI in CPM:
-
11 A'Y%
3
-Pa 0 if Leskage:Nrcen*e:5 6% j;100X i n e"11 - f _'(L in 6.,-N' 2)
Tbil',
A LTERAt,70N$'! .' DU . a SysteT41U""s HVAC E4u'iprr*iut Clizuje-Oih
E ntr Tested Leshage P bkw,i n*CMErom CTL6R:. Pr�-Test of EA i 7 t i n' g. I 5'u'd .3 rior 16
Dud System 'Ak&ation:a'nd'/-&rEtqtLipme4itCha ng:er 0 1 ut.
E niu- 7ewLedLesh",,Rbw,J wCPM.Flual Test ofNew Duct .3yetern, or -Altered DLctSyvtem
'forbL'va 3yeterri Alteration and/or &Tdrpre I nt.Cbsnj�,Out
El -79
6
Erilu, Redudion i vUAW- for, Alwed Dud System- [_(Li neI.4)Minlds (Line 1Y-5)]
'(6n ly�if',4ppl icatl6)
'Bnter'Pested Les) y,ifApj5
7--
B nii re New, Duct System.-. Pass i f Lea)66ge perc'eatage's
[I 00x irle. W.5)
0 -pass opail
1"ew CORTI
Use Ope of the follows p% four Test or'Veilllc ailob St aud ardstor coTopliauce.!
Pwcq'
tage:5'14% [100'.Kj�179Aine*5) 4-f-6'(Line#.-2)]],
Pass'b.Fa'il.
10
Pass i f Lealcage. to O..taidePementagq.:r.1 0% [.100 [_(Li'ncW
0 pass' 0 Tai I
nPercentage 604$ f 140 x
I and VO:rification,-by3moiceT,,estanziVieual,lnibn
0 Pasi '11I.Tail
12.'j*Psw'J
f Seal i rig Of's 11 Aocw�sibktesUsnd,,.Vex if Visual to ion'
1'0-Paw"113
Fail
Pan if Due of
LXJP4&w P Pai 1,
rse9me,cr,�r r_a�¢pLa,eee ca nes Ajif 2DDS
VIM
INSTALLATION CERTIFICATE (Page 3 of 12). CF -6R
Site Address Permit Number
44-oDUsteson Rd GriRey CA.959481 45-0621.0
-71
An installation certificate is required.to be:posted at bi ildiilg site or made available for all appropriate inspections: (The
information provided on'this form is required) After completion of final inspection; a cope inustbeprovided to"the building
department (upon request) and the building owner at occupancy, per Section 10-.103(a).
HVAC SYSTEMS:
Heating Equipment
Equip Type
k . heat um
CEC Certified Mfr:
Name and Model
Number
# of
;Identical
Systems
Efficiency
(AFUE; etc,)
ZCF-1R value)
Duct:
Location
attic etc.
' Duct or �
Piping
R -value
Heating
Load
Blu/hr -
Heating
Capacity'
Btu/hr
Package_, C_d
1111
F66-6
Ate t01
C6680
00
6
Cooling Equipment
Equip .Type
(pkg. heat um
CEC Certified Mfr.
Nameand Model
Number
# of
Identical
Systems
Efficiency
(SEER or EER)
ZCF=1R value)
Duel
Location
attic etc.
Duct
�R-value
Cooling
Load.,
Btu/hr
Cooling
Capacity
Btu/hr
Package,Ad
011
13 0'
Kt -tic -1
06
3 0
036000 '
D
1. > symbol reads greater than or equal to what is indicated on the CF -IR value..
Include SEER and EER if compliance credit for high'EER' air conditioner is claimed.
ve 11,
the undersigned, verify that equipment fisted above is: 1),is the actual equipment 1,
installed, 2) equivalent to or
more efficient than that specified in the certificate of compliance. (Form CF4R) submitted.. for compliance with the
Energy Efficiency Standards for residential, buildings, and 3) .equipment that meets or exceeds.,the appropriate
requirements for,manufactured devices (from the Appliance'Efficiency Regulations or Part 6), where applicable.
Installing.S' contractor (Co. Narile) OR General
Contra t ame) OR Owner
R.B._Spencet_Inc
.Date: 09/.1—.31061
Copies to: •DEPARTN 'T, AERS RATER (YF APPLICABLE) BYJTLD NG OWNER AT OCCUPANCY
Residential Compliance Forms .' Apid 2005
INSTALLATION CERTIFICATE
Site Address
440__Justeson_Rd Gridley CA..959.4.81
4of12
Permit Number
BP_0621.07J
INSTAL"LER COMPLIANCE STATEMENT FOR .DUCT LEAKAGE
INSTALLER COMPLIANCE STATEMENT
The building was: ✓ [_X rested at,Final ✓ [3 Tested at Rough -in
CF -
INSTALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE:
FX-]. Remove at least one supply and one return.register, and verify that the,spaces between the register boot and the interior
finishing wall are properly sealed.
IX J If the house rough -in duct leakage test was conducted without an air handler installed; inspect the connection points
between the air handler and the supply and return plenums to verify that the connection,points are properly sealed.
UX/ Inspect all joints to ensure that no cloth backed rubber adhesiveAuct tape is used.
rNew Distribution system is fully ducted (i.e., does not use building cavities as plenums or platforms returns in lieu of
✓ 0 DUCT LEAKAGE REDUCTION
Procedures for field veriFcation and diagnostic testine ofair distribution systems are availahln in R,4rM_ .4nnPndir Rrd_ ?
NEW CONSTRUCTION:
Duct Pressurization Test(CFM @ 25 Pa)
MeasuredResults
Sig r
Date; 09/1.3 0
Values
1
Enter Tested Leakage Flow in CFM:
Fan Flow: Calculated (Nominal: ✓ [)-(,Cooling ✓ ❑ Heating) or ✓ ❑ Measured
2
If Fan Flow is Calculated as 400 cfm/ton x number of tons or as 21.7 cfm/(kBtu/hr) x Heating
E14.76
Cavacity in Thousands of Btu/hr output, enter total. calculated or measured fan flow in CFM herd:
✓ ✓
3
Pass if Leakage Percentages 6%, for Final or.<_ 4% at Rough -in:
❑ Pass ❑ Fail
100 x Line #J) / Line # 2)11
ALTERATIONS:
Duct System and/or HVAC Equipment Change -Out
Enter Tested Leakage Flow in CFM from Pre -Test of Existing Duct SystemPrior to Duct
4
System Alteration and/or Equipment Change -Out:
`
Enter Tested Leakage Flow in CFM from Final Test of New Duct System or Alteied Duct
5
System for Duct System Alteration and/or Equipment Change -Out.
0_7_9.
.Enter Reduction in -Leakage for Altered.Duct System.
6
r Line# 4 Minus Line # 5 - Onl .if Applicable)
7
Enter Tested Leakage Flow in CFM to Outside (Only if Applicable).
✓
Entire New Duct System - Pass if Leakage Percentage S 6% for Final
8
100 x (Line # 5) / Line # 2
❑Pass ❑Fail
TEST OR VERIFICATION STANDARDS: For Altered Duct System and/or HVAC Equipment Change -
Out Use one of the following four Test or Verification Standards for compliance:
9
Pass if Leakage Percentage S 15% [100x[—Fl- Line # 5) /_ 1 7 _ (Line 2)]]
[�'2 1�
(XjPass ❑'Fail
10
Pass if Leakage to Outside Percentage!9 10% [100 x [ (Line.# 7) / (Line # 2)]]
❑ Pass ❑ Fail
Pass if Leakage Reduction Percentage >: 60% [ 100 x (Line # 6) / (Line A 4)]]
11
and Verification b Smoke Test and Visual Inspection
0. Pass ❑ .Fail
12
Pass i � ealin of all Accessible'Leaks and Verification by Smoke Test and Visual Inspection.
❑ Pass ❑ Fail
Pass if One of Lines # 9 through #A2 pass
F`Pass ❑ Fail
✓ ,.the undersigned, verify that the above diagnostic test results were performed in conformance with the requirements, for
compliance credit. 1, the undersigned, also certify that the newly installed'orretrofit Air -Distribution System,Ducts, Plenums and
Fans comply with Mandatory requirements specified in Section 150 (m) of the 2005,Building Energy Efficiency standards.
Arl
Installing Subco or (Co. Name) OR General
o OR Owner
Co actor (AM
R.B.-Spencer-Incl
Sig r
Date; 09/1.3 0
Copies to:.BUILDING DEPARTMENT, 4RS RATER (IF APPLICABLE) BUILDfNG OWNER AT OCCUPANCY
Residential Compliance Forms I September2005
INSTALLATION CERTIFICATE (Page 5; of 12) CF. -6R
Site. Address Permit'Number
440-Justeson.Rd_Gridley CA.959481 BP06210A
✓ CXj THERMOSTATIC EXPANSION VALVE (TXV)
Procedures for field verification of thermostatic expansion valves are'availdble'.in RACM, Appendix RI.
Access is provided for inspection. The procedure shall
consist ofe system 'visual verification that the TXV is installed on
Yes ❑ No the and installation of the specific equipment: TO
shall be verified.
a
✓ 0 REFRIGERANT. CHARGE"MEASUREMENT:
Verification for Required • Refrigerant Charge and. Adequate Airflow for Split System Space Cooling Systems without
TheriiiostaticEx�ansion Valves
Outdoor Unit Serial #
Location
Return (evaporator entering) air.dry-bulb temperaiure (Treturn, db)
Odtdoor.Unif Make
OF
Outdoor. Unit Model
Cooling Capacity
BtuAir
Date of Verification
OF
Date of Refrigerant Gauge Calibration
(must be checked monthly)
Date of Thermocouple Calibration
(must be checked monthly)
Standard Chane Measurement Proeedure (outdoor airdry-bulb 55T and above)
Procedures for Determining Refrigerant Charge using the Standard Method are available in RACM, Appendix RD2:
Note: The system should be installed.and charged'in accordance with the manufacturer's specifications before starting this
procedure.
Measured Tem eratures
Supply (evaporator leaving).air dry-bulb temperature (Tsupply, db)
OF
Return (evaporator entering) air.dry-bulb temperaiure (Treturn, db)
OF
Retum.(evaporator,entering) air wet -bulb temperature (Treturn, wb)
OF
Evaporator saturation temperature (Tevaporator, sat)
OF
Suction line temperature (Tsuction, db)
PF
Condenser'(entering) air dry-bulb temperature (Tcondenser; db)
OF
SUDerheat Charge Method Calculations fnr Refrioerant C'harffe
Actual Superheat = Tsuction,, db — Tevaporator, sat
OF
Target Superheat (from Table RD -2)
OF
-Actual Superheat —Target.Superheat*(System passes ifbetween.-5 and 4-5F)
PF
Temperature Split Method Calculations for Adequate Airflow
Split Method Calculation is not necessarv:ifAdeauate Airflow credit is."taken
Actual Temperature Split. = T. return, db Tsupply, db
OF
Target Temperature Split (from Table,RD3.),
OF
Actual Temperature Splih:Target,Temperature Split .(System passes if.between-
3°F and +3°F or, u on remeasurement if between -3°F and 400'F
of
Residential Compliance Forms, April 2005,
Sia n6rdCTiargeMe6surement'Sum mart':
pass tV refrippi rit0aige a ndkeik-'aik air 0&4 caldElation. d hmia, fr6nn'the sa me
an recalculated:'.
latel:'
Iv-- 1',IX.Yes' I ElVo-- I Syistm'Paiww-
Note f-nesyftm,' odfabeibwlall and cbarg6i; in man LL f1
urer.4 spea ications an
ver 1 flcati8n -06 11 rnenA�n,CF-6Rie Lbulbr a i f dry
i or, 6646; ifiiLa Ile r-'�,
Alierk&fe et aicair&&bMiARA RD-?.
ri.ChargingMetbod'for drigerant - arge
A6LLal liquidlirks"leingt:,
Man uf6ALLre"1'0,91a dzlarzl.,I'iq'Lid I ine l6ngt:
-Mah uf"ief's 6'prp'2"&'iz>n'(ou'how,
.Measured Ai rf btw Method for'iyk'RA CU AppepEdix"RD 2. 6,:,
Cal -1aiedAirO&cC&l.033'(cfftVB1u-
i n i ty'{B 0 b -CPM
Measured -Ai rf CPM (Meas-dred ai rflove, m'ust be•greater.lffi6 fi 066 Ic'ulited ai i Oo;tO.--
AlwnawCba rge Measukirp-61 3 umina ry
I jbal
y1em, a rge., ap.
refr igera nt ii 6" cai-�aat' memuremniR f:
cor recli ve"acl,ions U?ep-'igL';b61b criteria re- m�ewuied4nd recalculMe4
V -':[`O Yes.'J"O. N6' 1"SySif&'K' Passes)'
MM t ra do r (Co. Yi ire), PR Gre n era I
I ff;!�Kfi
)ue ner
01. ENC--Ege
b!kl 3/061
UING,131PARTM RS RATER'
Copick W EMEL #F A:PO CICABLIL) Ef EJ ILD LNG OWNER AT O -CCU PANC Yi
Re9�e;il al:CancPi,'a,eee To nes' ';April 2DO5
= OK
o = Not OK
MANUFACTURED HOMES
DATE U PERMANENT FOUNDATION U SOFT -SET
1 Zoning -Setbacks -Easements
2 Soils; Special MH Support Sketch
3 Sewer; Loctn Test; Fall/C/O-Concrete
4 Wtr; Loctn-Test-Easement Needed -Regulator
5 Elec Loctn-DImcs-Gmd Amp -Concrete
6 Yard Gas; Loctn Test Wrap Nat ❑ or LPO
Inch Sz Ft Lngth
7 Blckng; SzSpacing-Marriage Llne
8 Gas; MH Test-Demand-Valve-Cnnctr
9 Elec MH Cntnty Test-Crossovers-Breakers-Clrncs
10 Drain; MH Test -Fall -Flex Cnnctr
11 Wtr A Sewer Connected -C/O to Grade
12 Gas and Electricity. Tagged
13 Tie Downs ❑ Foundation ❑
14 Exits
15 Cert of Occupancy
16 HUD Labe(flnsignia Numbers Serial Numbers
o'6r ds o''r da
MISCELLANEOUS:'
0ECKS`C!DVERS'CARP0RTS'GARAGES
1 ZoningSetbacks-Easements
2 Ftgs; ScilsSr-DpthSpacing-CnnctrsSteel
;3 Decks, Girders/Jotsts-Dclgng-Brcing
Stairs-Guard/Handrails
4 Wood Awn; Posts-Beams-Rttrs-C_nnctrsShthg.
Frmg-Brcng
S. Alum Awn; Columns-CnnctrtsSplice4Decal-Encisrs
5 Carports; Wndws-Doors
7 Electric
_ 8 Frmg; Sills-AnchrsStuds-Rftrs Trtisses
_ 9 Siding; Nailing -Veneer -Stucco -Lath
10 Roof. Shthg-Roofing
-11 E) t; Steps-Doors-lartdtigs
-12 Braced Wall pnls
1 Setbacks -Easements
_ 2 Soils; Compaction -Structure Stability
_ 3 Pool Structure; Steel-Cnnctris-Thickness
Dead Men -Lining '
_ 4 Elec RcptdstUng; D-istance-GFl
_ 5 Elec Pool Laing; 15 volts-GFI
6 Elec.Enctkrs; Conduit Entries -Terminals -Listed
_ 7 Elec Bonding; Metal w/5'-Crcitng E� Itr
_ 8 Elec Grndng; Eqp m lW Crdtng Eqp-Pool Ightg
Bmces-Endsfs-pplboaids4nsulln•to Main Conduit
9 "ealth Dept App el .
_ 10 *Plmb; Cir Test-Wtr Supply Test
—i I Lt Niche ,
_12 Endsr; Fencing -Alarms
_ 13 Bonding, Diving board or Slide
dI- d o'er aT�
Pool Drawing
r
= Not
RESIDENTIAL (Single & Duplex)
DATE JUNDERFLOOR
1 ZoningSetbacks-Easements-RoodSlope
2 Fla Main; Soils-Elec Gmd Fig Dpth
3 Ftg Garage; SoilsSteel-Elec Gmd Ftg Dpth
4 Fig PorchesiDecks; Soils -Steel Fig Dpth
5 Stemwalls (Main; Steel-Blockouts Wrapped
6 Stemwalls Garage; Steel-BIockouts-Wrapped
6a Hold Downs and Special Anchrs
7 Slab, Steel Wrapped
8 Piers-Frplc FtgSteel
9 DW V; Fall -Fitting -Test -2 -way CIO -Sewer Test
10 UF, Gas Pipe; Sz Anchrs-Sz Test
11 Wtr Pipe; Test Anchrs-RgltrService Test
12 Elec Undrgmd
13• Plenums & Ducts; Cimc-MaterialSupport4asultn
14 GirdersSills-Anchr Bolts-Joists-Vnts-Cripples
15 Acc & Vntltn '
16 Insulation
DATE 15RAMING
17 Sills Proper Materials & Anchrs
18 Wills Studs -Nailing Spacing & Braces-PlatesSound
19 Bearing Walls over' Girder ;& fir Nailing
20 Draft Stop In Walls (rat prof) •
21 Fire Stops; Furred Ceilings -Stairs -Chasers -Tubs
22 Headers 13eams-bi &'Bearing'
23 Hangers-P•osf'Caps-Anch is-Cnnc ns
24 Ceiling Joisf-fir Tes-Purli -Roof Brac TnrssShthg
25 Frplc Tie's' or Type A Flu'&F ' Ic Throat Cimc
26 Attic Acr Sz &.'Binz Pitctn-Draft Stop -Ins Baffles
27 Bdrm Wnd*s or F_)iting DoorsSill fit & Dimensions
28 Garage Fire Prtdri Framing -RC Channel
29 Prprty Line Firewall & Opngs' .
30 Ext Doors One T -Check Gaiage 3rd Story, 2 Exits
31 Stairs; Wdtlraidnn4tise4bm4.and°my-FirePrbdn
32 Plywd on Roof Ovrhng-Mc Vnts-Ritr Outrgrs
33 Siding -Nailing Veneer -
34 Stucco Lath Weep Screed-Fndtn Vnts-Undrfir Ace
35 Glazing Area -Glass PrtctnSkyLts-Plastic .
36 Shear Walls; Nailing -Bolts
37 Brace IRI/Ext Wall pnls
38 lnsultn Walls -Ceilings
39 Infiltration -Walls Wndws
,r•
DATE JELECTRICAL
40 Fxtr & Tmsfrmr Clmc4ns Prtctn
41 Elec Rcptcls Spacing-Dts & Switches at Doors
42 Sz Boxes & No Of Cndctrs Stapled
43 Romex Installed Close to Edge of Studs & CJ
44 Egp Gmd made up w/Mech Fstnrs
45 Gmdng Electrode Bond Gas & Wtr
46 2 Appinc Cires in Ktchn & Cndctr Sz GFl
47 Subfeed Wire Sz Qa QCUor C AL
AC Wire Sz 9a Q CU or A�
48 Range Ciic w GU or AL
Oven Circ Qa CU or DAL
Insulated Neutral Yes ❑ No
49 Service -Riser Cndctrs & Grnd Main Dscand
50 Eqp Cimcs pnis-Motors-Meth Egp
51 Clothes Closet Lt-Shwr LI -Spa Lt
52 Smoke Detector
DATE PLUMBING
53 Wtr Htr, Vent-Acc-Cmbstn Air Baffle
54 Wtr Pipe; Test & Anchr-Nail Prtctn
_ 55 DWV; Test Fittings & Anchr Nail •Pr(ctn
56 Shwr Pan; Test, First fir -Tub Acc
57 Test Tutt & Shwr, 2nd fir - Tub Ace
58 Gas Pipe; Sz & Anchrs
59 Fire Sprinkler, Test
60 Yard Gas Piping
P
DATE M E C H-AA!'C-A L
Ducts Insulin & Support
62 Ven , Exhatist abv Insultn
LA and ate Drain & Ovrfiw, Sz & Grade -
&ri-Prmace-Vent Acc-Comb Air RbWent 115 Outlet
65 Attic Acc & Pltfrin if Furnace in attic
DATE IFINAL
66 Ext Steps -Door & SideU Pricbr-landings
67 Smoke Detector
68 Furnace Vnts-Cimc-Comb, Air-Dnndr
In Garage; abv-flr-Duds-Meth Prtctn
69 Bedroom Exiting
70 GFl A Bath Fxtrs & Tub Acc-Spa
71 GFl Arc Faun
72 Elee Trim & Subpnl, Breaker Szs & Labels
73 Stairs, GuardlHandraiis
74 Frplc or Stove, Cbnc-Hearth
75 Elec Outlets at Wood Pnl, Int & Ext
76 Ktchn, Fxtr & Appinc; Grnd-Air•Gap-Dooking Clmc
77 Elec Outlets & Rcptds A Ktchn Counter
78 Garage Fire Docr, Swing -Landing -Closure
79 AC Dud in Garage -Damper -
80 Wtr Htr Vnts-Cimc-Com Air Cnnctr-PRV; abv fir
Mech Prtctn; LPG Appince Undr House 3' drain
81 Plmb; Elec & Mech Eqp Listed for Loctn
82 Elec Rcptcls in Garage (GFQ Romex Prtcbn
83 Insults -Foam -Looked in Attic
84 Guard Rails & Deck Cnstrcin-Post Caps
85 Fndn Vnts & Crawl Hole Door Drnge & Wood -Earth
86 Cimc Dmge Planters Q Yes ONO
87 Stuno Brown -Finish
%e'AC Unit Dscnnc% Elec-Pimb
89 Vnts abv Roof, Plmb-Appinc-Frplc-Cimc to Opngs
90 Wtr Well, Dscnnd, Elec, Plmb
91 Ext Elec Trim, GFl Reptel-Undrgrnd
92 Vntltn thru House
93 Glass Prtctn
94 Corrections from previous lirspdns
95 Gas Test -Meters Tagged, Gas-Elec
96 W"ewer Cnndd-CIO to grade -HD Apprvi
ergy Cmpinc Cert -Other Certs
98 Address Posted
99 Fire Sprinkler
(0-ll-O(p C
dr �s. o+`' mss•
y 022-340-007.06-2170
PETER CHARLES' & KIM .
NOTES 440"JUSTESONRDf'GRIDLEY-"
Cont: OWNER `
' RE ROOF
RESIDENTIAL
APH: Permit No.
Owner.
Site Address:
Contractor.
Type of Permit: •
7"107,
SPECIAL
ti
{
SPECIAL CONDITIONS
CHECKED BY
0 SRA
Q FLOOD CERTIFICATE EQUIRED
Q FIRE SPRINKLERS REQUIRED
0 SPECIAL INSPECTION ITEMS
0 VERIFY
Q USE PERMIT CONDMCNS
Q SUBSTANDARD HOUSING LETTER
Q ENCROACHMENT PERMIT
Q REINSPECTION FEE PAID
Q ENV HLTH CLEARANCE
- F
f �
DATE JOB FPIALED:
SIGNATURE
A
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
PERMIT NO.
BP062170
PERMITS BECOME NULL AND VOID 1 YEAR FROM THE DATE OF ISSUANCE, OR IF WORK IS DONE IN VIOLATION OF ANY COUNTY OR STATE LAWS.
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: 09/11/2006 APN: 022-340-007-000
the Business and Professions Code, and my license is in full force and
effect.
Site Address: 440 JUSTESON RD GRI
License Class : License Number:
Map Index:
Date: Contractor:
Description:. REROOF 25 SQ COMP
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
Owner: PETER, CHARLES & KIM
permit to construct, alter, improve, demolish, or repair any structure, prior
to its issuance, also requires the applicant for such permit to file a
440 JUSTESON ROAD
signed statement that he or she Is licensed pursuant to the provisions of
GRIDLEY, CA
the Contractor's State License Law (Chapter 9 commencing with Section
95948
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 Section 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
�t
sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Applicant: PETER, CHARLES & KIM
Code: The Contractors' State License Law does not apply to an
440 JUSTESON ROAD
owner of property who builds or improves thereon, and who does
such work himself or herself or through his or her own employees,
GRIDLEY, CA
provided that such improvements are not intended or offered for
95948
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 of the property, am exclusively contracting 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.).
❑ 1 am Exempt under Article 3 of he Business and Professions Code
Date:q__ -h l Owner: , ,k"T'a' P It 0 _Q 9 bh
License #:
WORKERS' 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
Labor Code, for the performance of the work for which this permit
Architect:
is issued.
Engineer:
❑ I 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:
Total Square Ft: 0 S.F.
Policy#:
Valuation: $0.00
Census Code:
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: 9-11—in
Applicant
/s V T
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 attorney's fees.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
This permit is hereby issued under the applicable provisions of the Butte County C de a d/or
Resoluf do work in i ated ve f r which fees have been paid.
performance of the work for which this permit is issued (Sec 3097 Civ.)
BY' Date: 4
Name:
,Lr
P IT EXPIRES ON: l -
Address:
ate
❑ 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 19827.5 of California Health & 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 owner. I agree to comply with
all coupty and state laws relating to building construction. I acknowledge it is unlawful to alter the substance of any official form or document of Butte County. I hereby
authorize represe tatives of Butte County to enter upon the above mentioned property for inspection purpos s.
�--
�D
Print Name:j �l C� "T �' i C i Slgnature� Pit P I P h
Date: 9—1 fl'—o
Owner ❑ . Contractor ❑ Agent for Owner ❑ Agent for Contractor
B. C. Building Permit 01.16-04 pg 1
. =OK
o = Not OK
MANUFACTURED HOMES
UA 11:-- " PERMANENT FOUNDATION U SOFTSET
1 ZoningSeibacks-Easements
2 Soils; Special MH Support Sketch
3 Sewer; Loctri-Test; FalUC/0-C6ncrete
4 Wtr. Loctn Test-Easeinent Nebded-Regulator
5 Elec Loctn-Clmcs-Gmd "Amp -Concrete
6 Yard Gas; Loctn Test Wrap Nat ❑ or LPQ
Inch Sz Ft Lngth
T Blckng; SzSpacing-Marriage Line
8 Gas; MH Test-Demand-Valve-Cnnctr
9 Elec MH Cntnty Test-Crossovers-Breakers-Clmcs
10 Drain; MH Test -Fall -Rex Cnnctr
11 Wtr & Sewer Connected -C/O to Grade
12 Gas and Electricity Tagged
13 Tie Downs Q Foundation Q
14 Exits.
15 Cert of Occupancy
16 HUD LabeUtnsignia Numbers Serial Numbers
MISCELLANEOUS-
DECKS-CQVERS-CARP0RTS'GARAGES
1 ZoningSetbacks-Easements
2 Ftgs; ScilsS"pthSpacing-CnnctrsSteel
3 Decks, Girders/Joists-0cking-Brcing
Stairs-CuardlHandralls
4 Wood Awn; Posts-Beams-Wtrs-CnndrsShthg•
Frmg-Brcng
5 Alum Awn; Columns-CnnctnsSplice-Decal-Encisrs
6 Carports; Wndws-Doors
T Electric
8 Frmg; Sills-AnchrsStuds-Ritr's Trusses
9 Siding; Nailing-VengerStucco-Lath
10 Roof. Shthg-Roofing
11 Ei(� Steps -Doors- andnigs
12 Braced Wall pnls
1 Setbacks -Easements
2 Soils; Compaction -Structure Stability
3 Pool Structure; Steel-Cnnctns Thickness
Dead Men -Lining
4 Elec RcptdsAAng; Distance-GFI
5 Elec Pool Lting;15 volts-GFI
6 Elec.Eridsrs; Conduit Entries-TprminaLsListed
7 Elec Bonding; Metal wlW-Crdtng Egp-Htr
8 Elec Gmdng; Eqp w/5' Crcltng Eqp-Pool Ightg
Saxe S-Enclsts-pntboards-lnsultn-to Main Conduit
9 Health Dept Appivt
10 'Plmb; Cir Tett-Wtr Supply Test
11 Lt Niche ,
12 Endsr; Fencing -Alarms
13 Boi)dmg. Diving board or Slide
�`- d41 dcT�
Drawing
Not OK
RESIDENTIAL (Single & Duplex)
DATE JUNDERFLOOR
1 ZoningSetbacks-Easements-FloodSlope
2 Ftg Main; Soils-Elec Gmd Ftg Dpth
3 Ftg Garage; SoilsSteel-Elec Gmd Ftg Dpth
4 Ftg Parches/Decks; Soils -Steel Ftg Dpth
5 Stemwalls Wain; Steel-Blockouts Wrapped
6 Stemwalls Garage; Steel -Blackouts -Wrapped
6a Hold Downs and Special Anchrs
7 Slab, Steel Wrapped
8 Piers-Frple Ftg-Steel
9 DWV; Fall -Fitting -Test -2 -way C/0 -Sewer Test
10 UF, Gas Pipe; Sz Anchrs-Sz Test
11 Wtr Pipe; Test-Anchrs-RgitrService Test
12 Elec Undrgmd
13 Plenums & Ducts; Cimc-MaterialSupportansultn
14 GirdersSlits-Anchr Bolts-Joists-Vnts-Cripples
15 Ace & Vntltn '
16 Insulation
a' v?� o'�d o`s•
DATE 15RAMING
1T Sills Proper Materials & Anchrs
18 Walls Studs -Nailing Spacing & Braces -Plates -Sound
19 Bearing Walls ovet Girders:,& flr Nailing
20 Draft Stop In Walls (rat proof) •
21 Fire Stops; Furred Ceilings -Stairs -Chasers -Tubs
22 Headers & Beams -Si &'Bearing
23 Hangers-P•osf:Caps Andrus-Cnnchu
24 Ceiling Joist-Rf6'Tres-Purli--Roof Brac-Truss
25 Frplc Tiietk
s'or Type A Flut3=F ' Ic Throat Clrnc
l
26 Attic Ace; Si WRmX )'it -0raft Stop4ns Baffles
27 Bdrm Wndws or FYiting Doors -Sill "t & Dimensions
28 Garage Fire Prtchi Framing -RC Channel
29 Prprty Line Firewall & Opngs' .
30 Ext Doors -One 3' -Check Gaiage 3rd Story, 2 Exits
31 Stairs; Wid"drm-Rise-Rum-Landing-Fire Prtctn
32 Plywd on Roof Ovrhng-Attic Vnts4ft Otitrgrs
33 Sidurg-Nailing Veneer
34 Stucco Lath -Weep Screed-Fndtn Vnts-Undrflr Ace
35 Glazing Area -Glass PrtctnSkyLts-Plastic .
36 Shear Walls; Nailing -Bolts
37 Brace Int/Ext Wall pnls
38 insults Walls -Ceilings
39 Infiltration Walls-Wndws
0.4'
DATE JELECTRICAL
40 Fxtr & Tmsfmur Clmc4ns Prtctn
41 Elec Rcptcts Spacing-Lts & Switches at Doors
42 Sz Boxes & No Of Cndctrs Stapled
43 Romex Installed Close to Edge of Studs & CJ
44 Eqp Gmd made up w/Mech Fstnrs
45 Gmdng Electrode Bond Gas & Wtr
46 2 Appinc Cires in Ktchn & Cndctr Sz GFl
47 Subfeed Wire Szua OCU or ❑AL
AC Wire Sz Qa O Cu or O AL
48 Range Circ w OCU or DAL
Oven Circ Q, O cu. DAL
Insulated Neutral Dyes ON.
49 Service -Riser Cndctrs & Gmd Main Dscnnct
50 Eqp Cimcs pnls-Motors-Meth Eqp
51 Clothes Closet UShwr LI -Spa Lt
52 Smoke Detector
0
DATE IPLUMBING
53 Wtr Htr; Vent-Acc-Cmbstn Air Baffle
54 Wtr Pipe; Test & Anchr-Nail Prtctn
55 DWV; Test Fittings & Anchr. Nail •Prfctn
56 Shwr Pan; Test, First fir Tub Ace
57 Test Tuti & Shwr, 2nd fir - Tub Ace
58 Gas Pipe; Sz & Anchrs
59 Fire Sprinkler; Test
60 Yard Gas Piping
A �
DATE MECHANICAL
61 AC Ducts Insulin & Support
62 Vent Fan, Exhaust abv Insulin
63 Condensate Drain & Ovrflw, Sz & Grade -
64 Furnace -Vent Acc-Comb Air Rtrn/Vent 115 Outlet
65 Attic Ace & Pltfrin if Furnace in attic
DATE FINAL
66 Ext Steps -Door & SideLt Prtctn-landings
67 Smoke Detector
68 Furnace Vnts-Cimc-Comb, Air-Cnnctr
In Garage; abv4lr-Duds-Mech Prtctn
69 Bedroom Exiting
70 GFl 8 Bath Fxtrs & Tub Ace -Spa
71 GFl Are Fault
72 Elec Trim & Subpnl, Breaker Szs & Labels
73 Stairs, Guard/Handrails
74 Frplc or Stove, Ctmc-Hearth
75 See Outlets at Wood Pnl, Int & Ext
76 Ktchn, Fxtr & Appinc; Grnd-Air-Gap-Cooking Cimc
77 Elec Outlets & Rcptcls A Ktchn Counter
78 Garage Fire Door Swing-tartding-Closure
79 AC Duct in Garage -Damper.
80 Wtr Htr; Vn s-C1mc-Com Air Cnnctr-PRV; abv fir
Mech Prtctn; LPG Appince Undr House 3' drain
81 Plmb; Elec & Mech Eqp Listed for Loctn
82 Elec Rcptcls in Garage (GFl) Romex PrtcIn
83 Insuitn-Foamdooked in Attic
84 Guard Rails & Deck Cnstrctn-Post Caps
85 Fndn Vnts & Crawl Hole Door Drnge & Wood -Earth
86 Cimc Dmge Planters O Yes O No
87 Stucco Brown -Finish
88 AC Unit Dscnnct, Elec-Pimb
89 Vnts abv Roof, Plmb�lppinc-Frple-Cimc to Opngs
90 Wtr Well, Dscnnc% Elec, Pimb
91 Ext Elec Trim, GFl RcptcI-Undrgmd
92 Vntitn thru House
93 Glass Prtctn
94 Corrections from previous litspans
95 Gas Test -Meters Tagged, Gas-Elec
96 Wtr & Sewer Cnnctd-C/0 to grade -HD Apprvl
97 Energy Cmpinc Cert -Other Certs
98 Address Posted
99 Fire Sprinkler
oco Q_� G
o'r ds d da
EFI� c�n9P t S l ticG,' a( S`Ti4C C Ei�
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
PERMIT NO.
BP062170
PERMITS BECOME NULL AND VOID 1 YEAR FROM THE DATE OF ISSUANCE, OR IF WORK IS DONE IN VIOLATION OF ANY COUNTY OR STATE LAWS.
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I licensed under Issued Date: 09/11/2006 APN: 022-340-007-000
provisions of Chapter 9 (commencing with Section 700000 ) of Division 3 of
the Business and Professions Code, and my license is in full force and
effect.
License Class : License Number: Site Address: 440 JUSTESON RD GRI
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 pursuant 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 Section 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
intended or offered for sale (Sec. 7044, 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 of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
1 and Professions Code. The Contractors' State License Law does
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 Exempt under Article 3 of he Business and Professions Code
Date:q z:b ( Owner: } 1') p p -Q � - th
WORKERS' 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
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 attorney's fees.
Map Index:
Description:. REROOF 25 SID COMP
Owner: PETER, CHARLES & KIM
440 JUSTESON ROAD
GRIDLEY, CA
95948
Applicant: PETER, CHARLES & KIM
440 JUSTESON ROAD
GRIDLEY, CA
95948
Contractor:
License #:
Architect:
Engineer:
Total Square Ft: 0 S.F.
Valuation: - $0.00
Census Code:
$ + v/ /,-Y, D
"
t/37 J -D
CONSTRUCTION LENDING AGENCY This permit is hereby issued under the applicable provisions of the Butte County C de a d/or
I hereby affirm that there is a construction lending agency for the Resolut' do work in i ated ve f r which fees have been paid.
performance of the work for which this permit is issued (Sec 3097 Civ.) 9 `
Name: BY' Date:
P IT EXPIRES ON: l .
Address:
-• ate
❑ I 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 19827.5 of California Health & 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 owner. I agree to comply with
all couhty and state laws relating to building construction. I acknowledge it is unlawful to alter the substance of any official form or document of Butte County. I hereby
authorize represe tatives of Butte County to enter upon the above mentioned property for inspection purpos s.
Print Name ) %� �� j'% P . ��'7c Slgnature'� �J
Date:
Owner
❑ Contractor
❑ Agent for Owner
❑ Agent for Contractor
B. C. Building Permit 01-16-04 pg 1
s
OWNER -BUILDER VERIFICATION
Attention Property Owner:
An "owner -builder" building permit has been applied for in your name and bearing your
signature.
Please complete and return this information at your earliest opportunity to avoid unnecessary
delay in processing and issuing your building permit. No building permit will be issued until this
verification is received.
I personally plan to provide the major labor and material for construction of this proposed
property impr vement: YES [>(I NO[ ].
2. I HAVE [] HAVE NOT [ ] signed an application for a building permit for the proposed
work.
3. I have contracted with the following person (firm) to provide the proposed construction:
NAME:
ADDRESS: ,
PHONE: CONTRACTOR'S LICENSE NO:
4. I plan to provide portions of the work, but I have hired the following person to coordinate,
supervise, and provide the major work:
NAME:
ADDRESS: '
PHONE: CONTRACTOR'S LICENSE NO:
5. I will provide some of the work but I have contracted _(hired) the following persons to provide
the work indicated:
NAME ADDRESS PHONE TYPE OF WORK
SIG D:
PROPERTY OWNER:
DATE: 9 -/ l _bZ
NOTE: This Owner -Builder verification is required by Section 19831 and 19832 of the California
Health and Safety Code.
This verification must be completed and returned to our office before we are permitted to issue the
permit.
Rev'd 11/4/2004
JW_
Butte County Department of Development
Services
TIM SNELLINGS, DIRECTOR I PETE CALARCO, ASSISTANT DIRECTOR
7 County Center Drive
Oroville, CA 95965
(530) 538-7601 Telephone
(530) 538-7785 Facsimile
www.buttecounty.net/dds
OWNER -BUILDER INFORMATION
Dear Property Owner:
An -application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "owner -builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their own
work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if
that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the city or county. They are also required by law to put their license number on all permits for which they apply.
If you plan to do your own work, with the exception of various trades that your plan to subcontract, you should be
aware of the following information for your benefit and protection:
o If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $500 or more for the entire project and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
o If you are an employer, you must register with the state and federal government as an employer and you are subject
to several obligations including state and federal income tax withholding, federal social security taxes, workers'
compensation insurance, disability insurance costs, and unemployment compensation contributions.
o There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious
with respect to workers' compensation insurance. .,
o For more specific information about your obligations under federal law, contact the Internal Revenue Service (and,
if you wish, the U.S. Small Business Administration). For more specific information about your obligations under
state law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractor is to secure an "owner-builder"=building
permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building
permits are not required to be signed by property owners unless they are performing their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board's
automated telephone information system at 1-800-321-CSLB (2752) or by accessing their website at www.CSLB.ca.gov.
Please complete and return the enclosed owner -builder verification from so that we can confirm that you are aware
of these matters. The building permit will not be issued until the verification is returned.
Sincerely,
A ti
Scott Rutherford
Manager, Building Divi ion
NOTE: This Owner -Builder Information is required by Section 19830 of the California Health and Safety Code.
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATION
AND SUBMITTAL REQUIREMENTS
OFFICE #: (530) 538-7541
A FEE WILL BE REQUIRED AT TIME OFAPPLICA TION
Website: www.buffecounty.net/dds
"PLEASE PRINT CLEARLY"
OWNER INFORMATION
am
i Name
M ili A dr s
Address
Stat
Zi
Phon
U- g4lb
Fax
E-mail
APPLICANT INFORMATION
CONTRACTOR
Name
Cit
Address
Stat
City
Phon 1 d
State
Zip
Phone
Map Book
Fax .
E-mail
Planner
Lic. #
Class
APPLICANT INFORMATION
ARCHITECT/ENGINEER
Name
Cit
Address
Stat
City
Phon 1 d
State
7zip
Phone
Map Book
Fax
E-mail
Planner
State License Number
APPLICANT INFORMATION
Name
Address
Cit
Cross Street
- C:2r
Stat
�I
Phon 1 d
Fax
E-mail
APPLICANT SIGNATURE
X
For office use only:
Zoning
Property Address
Flood Zone
Cross Street
- C:2r
SRA
I Yes
I No
Occ.
Type Const,
Subdivision Name
Map Book
Page
Lot #
Planner
Date Approved:
OVER FOR SUBMITTAL REQUIREMENTS
PERMIT
NO.
BP()� 0
BIN #
PROJECT LOCATION
AN
- -COO
Property Address
Ci
e
Cross Street
- C:2r
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:
24 DE --
Sq FT- Living Garage Open Cov
❑ 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
required.
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.
Received by: Amount:
Bldg
SRA
Receipt #:
Sheriff
SMIP
Date: Q11 d�
Other
Total
K:\Building\WEBSITE FORMS\BldgApplSubRgmts82506.doc Page 1 of 2
REV 8-25-06
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 faxesl
❑ 4. Energy compliance design and supporting documentation in duplicate.
❑ 5. Statement of Intent for Non -heated and A/C for Non -Residential Buildings.
Cl 6. Manufactured homes: (A) Installation manual, (B) Marriage line info, (C) Floor Plan, (D) Tie down or fnd plans,
(E) Manufactured Home Support Data (form available on our website) 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 (if building in the City of Biggs).
❑ 10. Letter of intent for non-residential buildings.
❑ 11. Building Permit Application Without Required Clearances Form
❑ 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). If your project is located in State
Responsibility Area (SRA), you are required to meet the SRA Fire Safe Requirements sheet.
❑ 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. ❑ Legal description from current recorded grant deed, ❑ Copy of M.H. Title, Title transfer, or MCO.
❑ 12. Sanitation and site plan approval from the Environmental Health Department.
❑ 13. Planning Division approval for parcel check, use and parking (if required).
If you have questions or would like additional information regarding this process, please contact a
Permit Assistant at (530) 538.7541.
A FEE WILL BE REQUIRED AT TIME OF APPLICATION.
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
KABuilding\WEBSITE F0RMS\B1dgApp1SubRgmts82506.doc Page 2 of 2 REV 8-25-06
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT ' 1
24 HOUR IN #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541 FAX#: (530)538-2140
WEBSITE: www.buttecounty.netldds
PERMIT NO.
BP062107
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: 08/31/2006 APN: 022-340-007-000
the Business and Professions Code, and my license is in full force and
effect.
0
License Class: : Li se umbo 4
Site Address: 440 JUSTESON RD GRI
Date: ME Contractor.
Map Index:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty' of perjury that I am exempt from the
Description: HVAC CHANGE OUT
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
Owner: PETER, CHARLES 8& KIM
to its issuance, also requires the applicant for such permit to file -a
440 JUSTESON ROAD
signed statement that he or she is licensed pursuant to the provisions of
the Contractor's Slate License Law (Chapter 9 commencing with Section
GRIDLEY, CA
7000) of Division 3 of the Business and Professions Code) or that he or
95948
she is exempt therefrom and the basis for the alleged exemption. Any
violation of Section 7031.5 by any applicant for a permit subjects the
applicant to a civil penalty of not more than five hundred dollars ($500).):•
O 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 (Sec. 7044, Business and Professions
Code: The Contractors' State License Law does not apply to an
Applicant: SPENCER INC., R. B.
owner of property who builds or improves thereon, and who does
such work himself or herself or through his or her own employees,
1188 HASSETT AVENUE
provided that such improvements are not intended or offered for
sale. If however, the building or improvements are sold within one
YUBA CITY, CA 95993
year of completion, the owner -builder will have the burden of
530-674-8307
proving that he or she did not build or improve for the purpose of
sale.).
O -I, as owner of 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 property who builds or improves thereon,
Contractor: SPENCER INC., R:B.
and who contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
1188 HASSETT AVENUE
❑ I am Exempt under Article 3 of the Business and Professions Code
YU BA CITY, CA 95993
530-674-8307
Date: Owner:
License #: 664429
WORKERS' 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
Labor Code, for the performance of the work for which this permit
Architect:
is issued.
I have and will maintain workers' compensation insurance, as
Engineer:
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:
?� 417777
Carrier:
Total Square Ft: 0 S. F.
�
Policy #:_ jl�Ga c�-
CZJ
Valuation: $0.00
❑ I certify that in the performance of the work for which this permit is
Census Code:
issued, I shall not employ any persons any manner so as
become subject to the workers' compensation laws of California,a,
and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply wi h those provisions.
Date. i
J
Appli
WARNING: Failure to secure workers' co em ation coverage is
unlawful, and shall subject an employer to cr inal 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 attorney's fees.
_ CONSTRUCTION LENDING AGENCY,
I hereby affirm that there is a construction lending agency for the
This permit is hereby issued under the applicable provisions of the Butte County Godo a ft/Or
" Resolutio t 'do work to I ted e f which fees have been paid. — -
performance of the work for which this permit is issued (Sec 3097 Civ.)
Name:
r 6
B Date: 5�
PERMIT EXPIRES ON:
Address:
ate
❑ I hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safely Code, which regulate the storage,
handling and use of hazardous materials.
❑ Notification in accordance with Section 19827.5 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 ort duly authorized agent of the owner. I agree to comply with
all county and state ws relating to building construction. I acknowledge It is unlawful to alter th ubstance of/a Ial form or document of Butte County. I hereby
authorize repro olives of Butte Co my enter poo a above mentioned property for inspe tion purpo �,s
Print Name: Signal
Date: e''�
0 Owner ❑ Contractor ❑ Agent for Owner 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 TIME OFAPPLICA TION
Website: www.buttecounty.nettdds
"PLEASE PRINT CLEARLY"
OWNER INFORMATION
CONTRACTOR
Name
city-
Address
CL
'V _ '3 3�
7 �/
tie
Zip
FA
APPLICANT INFORMATION
CONTRACTOR
Name
city-
Address
CL
'V _ '3 3�
7 �/
tie
Zip
�
P✓ J0 �7 —
Map Book
Fax
E-mail
Planner
cWON 2,sL
FA
APPLICANT INFORMATION
ARCHITECT/ENGINEER
Name
city-
Address
WET�
City
'V _ '3 3�
7 �/
State
Zip
Phone
Map Book
Fax
E-mail
Planner
State License Number
FA
APPLICANT INFORMATION
Name
Addm
city-
Sew—
WET�
Phone C
�J
'V _ '3 3�
7 �/
E-mail
IFAMMENVA,V
Mir
For office use on y:
Zoning
Flood Zone
SRA
I Yes
No
Occ.
Type Const.
Subdivision Name
Map Book
Page
Lot #
Planner
Date Approved:
OVER FOR SUBMITTAL REQUIREMENTS
PERMIT
NO.
P
BIN #
PROJECT /L''O�CATION
AP# /1 ��–� lJ — "' o
PX
p y Addr s ity
i
Cross Street
WORKER'S COMPENSATION
Carrier
7
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
Descri=orscope'Work:
J
Sq FT- Living Garage Open Cov
❑ 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
required.
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.
Received by: Amount: Bldg
SRA
Receipt #: [� I `l Sheriff
Date:
SMIP
K:\FORMS\BUILDING FORMS\BldgApplSubRgmts.doc Page 1 of 2 REV 8-12-05
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 manual, (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. Building Permit Application Without Required Clearances Form
❑ 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.
❑ Legal description from current recorded grant deed, ❑ Copy of M.H. Title, Title transfer, or MCO.
❑ 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 8-12-05
--,
NOTES
t'
PERMIT NO.
RESIDENTIAL
_ 022.340-007 04-1032 �—
( PETER, CHARLES
440 JUSTESON RD, GRIDLEY,.
Cont:.ECKELBARGER & SON
STUCCO HOUSE(1820)
`J >
A -G- -'4"
SPECIAL CONDITIONS
SRA
FLOOD CERTIFICATE REQ
FIRE SPRINKLERS REQ
SPECIAL INSPECTION ITEMS
VERIFY
USE PERMIT CONDITIONS
SUB -STANDARD HOUSING LETTER
JOB FINALED a ) "
C,
Signatur
i -
CHECKED
BY
s,
k'
7
A
4*
Y
1
i•
4
i
t
t
RESIDENTIAL
_ 022.340-007 04-1032 �—
( PETER, CHARLES
440 JUSTESON RD, GRIDLEY,.
Cont:.ECKELBARGER & SON
STUCCO HOUSE(1820)
`J >
A -G- -'4"
SPECIAL CONDITIONS
SRA
FLOOD CERTIFICATE REQ
FIRE SPRINKLERS REQ
SPECIAL INSPECTION ITEMS
VERIFY
USE PERMIT CONDITIONS
SUB -STANDARD HOUSING LETTER
JOB FINALED a ) "
C,
Signatur
i -
CHECKED
BY
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.netldds
PERMIT NO.
BP041032
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: 04/14/2004 APN•' 022-340-007-000
the Business and Professions Code, and my license is in full force and
effect.
License Class : License Number:
Site Address:
Date: Contractor:
Map Index:
Description: STUCCO HOUSE (1820)
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
Owner: PETER, CHARLES & KIM
to its issuance, also requires the applicant for such permit to file a
440 JUSTESON ROAD
signed statement that he or she is licensed pursuant to the provisions of
the Contractor's Slate License Law (Chapter 9 commencing with Section
GRIDLEY, CA
7000) of Division 3 of the Business and Professions Code) or that he or
95948
she is exempt therefrom and the basis for the alleged exemption. Any
violation of Section 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
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors' State License Law does not apply to an
Applicant: PETER CHARLES &KIM
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 of 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 property who builds or improves thereon,
Contractor: ECKELBARGER & SON
and who contracts for such projectsIyvith a contractor(s) licensed
pursuant to the Contractors' State Lig nse Law.).
440 JUSTESON RD.
sions Code
❑ I am Exempt under Article 3of th /77/0/,1
GRIDLEY, CA 95948
530-534-9871
bate: Owner:
License #:
WORKERS' COMPS SATION D CLARATION
I hereby affirm under penally 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
Architect:
is issued.
❑ 1 have and will maintain workers' compensation insurance, as
Engineer:
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.
Total Square Ft: 0 S. F.
Policy #:
Valuation: $0.00
I certify that in the performance of the work for which this permit is
Census Code:
/ 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.
���
�
[/fJ_
Date:
*ZOO �-•
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 attorney's fees.
CONSTRUCTION LENDING AGENCY
This p it is ere is a der he pplicable rovisions of the Butte County Code an /or
I hereby affirm that there is a construction lending agency for the
Res I io o do o is r c ee ha been paid. d
performance of the work for which this permit is issued (Sec 3097 Civ.)
L�-
Name:
By: Date:
PERMIT EXPIRES ON: 4114/0
Address:
91
ate
❑ I 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 19827.5 of California Health & 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 ly a thorize a ent of the owner. I agree to comply with
all county and state laws relating to building construction. 1 acknowledge it is unlawful to alter the substance of an ffici form d current of Butte County. I hereby
authorize representatives of Butte County to en upon the above mentioned property for inspection purposes. r
���G2 /
Print Name:14Z/� Signature:
Date: ��r /I (l /:�,
Owner ❑ Contractor ❑ Agent for Owner 0 Agent for Contractor
J=OK
0 = Not OK
. = Not Readyable� MOBILE HOMES
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/0-Concrete
4. Water; Location-Test-Easement Needed (Sketch)
5. Electricity; Location-Clearances-Grnd-/ /Amp-Concrete
6. Gas; Location-Test-Wrap;-/ P' L'ft.
/ P Nat. or/ /" L "ft./ P LPG
MISCELLANEOUS
7.
Well Clearance & Disconnect
1.
8.
Utility Clearance
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.
Date
6.
Card B-1 Date Card B-1
Date
Electric
Card B-1 Date Card B-1
Date
MOBILE HOME INSTALLATION (Plans) OK except #'s
10.
1.
Zoning Requirements -Setbacks -Easements
Ext.; Steps -Doors -Landings
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 -Connector
7.
Water and Sewer Connected -C/0 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
Card 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 Card B-1
MISCELLANEOUS
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-GFI
5. Elec.; Pool Lighting; 15 Volts-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
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-GFI
5. Elec.; Pool Lighting; 15 Volts-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
J=OK
0 = Not OK
- = Not Applicable
. = Not Ready
RESIDENTIAL (Single & Duplex)
Date
UNDERFLOOR (Plans) OK except #'s
1.
Zoning -Setbacks -Easements -Flood -Slope
2.
Ftg., Main; Soils-Elec. Grnd.-/ /" Ftg. Depth
3.
Ftg., Garage; Soils-Steel-Elec. Grnd.-/ /" Ftg. Depth
4. Ftg., Porches & Decks; Soils -Steel-/ /" Ftg. Depth
Attic Access; Size & Romex Protection -Draft Stop -Ins. Baffles
5.
Stemwalls, Main; Steel-Blockouts-Wrapped
_
6.
Stemwalls, Garage; Steel-Blockouts-Wrapped
Garage Fire Protection Framing -RC Channel
6a.
Hold Downs and Special Anchors
7.
Slab, Steel -Wrapped
8.
Piers -Fireplace Ftg.-Steel
9.
D.W.V.; Fall -Fitting -Test -2 Way C/0 -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
Card B-1 Date Card B-1
Date
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
PLUMBING (Permit) OK except #'s
66.
17.
Water Htr.; Vent -Access -Combustion Air Baffle
67.
18.
Water Pipe; Test & Anchor -Nail Protection
68.
19.
D.W.V.; Test Fittings & Anchor -Nail Protection
69.
20.
Shower Pan; Test, First Floor -Tub Access
70.
21.
Test Tub & Shower, Second Floor -Tub Access
71.
22.
Gas Pipe; Sixe & Anchors
72.
23.
Fire Sprinkler; Test
73.
Kit. Fixt. & Appliance; Ground -Air -Gap -Cooking Clearance
Date
Elec. Outlets & Receptacles at Kit. Counter
Card B-1 Date Card B-1
Date
Garage Fire Door; Swing -Landing -Closure
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 Al
_
31.
Range Circle/ /ga Cu or AI -Oven Circ. / /ga Cu or Al
Insulated Neutral 0 Yes O 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
89.
Ventilation Throughout House
Date
90.
Card B-1 Date Card B-1
Date
91.
Card B-1 Date Card B-1
Date
MECHANICAL (Permit) OK except #'s
Gas Test -Meters Tagged, Gas -Electric
36.
A.C. Ducts Insulation & Support
Water & Sewer Connected -C/O to Grade -HD Approval
37.
Vent Fan, Exhaust above insulation
Energy Compliance Certificate -Other Certificates
38.
Condensate Drain & Overflow, Size & Grade
Address Posted
39.
Furnace -Vent Access -Comb. Ait-Return Air Vent 115 Outlet
Fire Sprinkler
40.
Attic Access & Platform if Furnace in Attic
Date
Date
Card B-1 Date Card B-1
Date
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 A Flue -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 3' -Check Garage 3rd Story, 2 Exits
55.
Stairs; Width -Headroom -Rise -Run -Landing -Fire Protection
56.
Plyw od on Roof Overhang -Attic Vents -Rafter Outriggers
57.
S' ng -Nailing Veneer
tucco Mesh -Drip Screed -Fd. Vents-Underflr. Access
9.
60.
Glazing Area -Glass Protection -Skylights -Plastic
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, Air -Connector -
In Garage; Above Floor-Ducts-Mech. 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 O Yes
_
FoWing Instld./Drive O Yes 0 No/Walks D Yes O No/Planters O Yes O No
tucco 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.
Fire 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:
`1
-At.
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.netldds
PERMIT NO.
BP041032
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: 04/14/2004 APN: 022-340-007-000
the Business and Professions Code, and my license is in full force and
effect.
License Class : License Number:
Site Address:
Date: Contractor:
Map Index:
Description: STUCCO HOUSE (1820)
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
Owner: PETER, CHARLES & KIM
to its issuance, also requires the applicant for such permit to file a
440 JUSTESON ROAD
signed statement that he or she is licensed pursuant to the provisions of
the Contractor's State License Law (Chapter 9 commencing with Section
GRIDLEY, CA
7000) of Division 3 of the Business and Professions Code) or that he or
95948
she is exempt therefrom and the basis for the alleged exemption. Any
violation of Section 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
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors' State License Law does not apply to an
Applicant: PETER, CHARLES &KIM
pp
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 of 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 property who builds or improves thereon,
Contractor: ECKELBARGER & SON
and who contracts for such projects ith a contractor(s) licensed
pursuant to the Contractors' State Lio nse Law.).
440 JUSTESON RD.
❑ la Exempt under Article 3of th us' ess Code
GRIDLEY, CA 95948
wr
530-534-9871ions
Date: Owner:
License #:
WORKERS' COMPE SATION D CLARATION
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
Labor Code, for the performance of the work for which this permit
Architect:
is issued.
❑ I have and will maintain workers' compensation insurance, as
Engineer:
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.
Total Square Ft: 0 S. F.
Policy #:
Valuation: $0.00
1 certify that in the performance of the work for which this permit is
Census Code:
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
forthwithth comply those provisions.
Date:
Applicant:v�O
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 attorney's fees.
CONSTRUCTION LENDING AGENCY
This p it is ere is a er a pplicable rovisions of the Butte County Code an /or
I hereby affirm that there is a construction lending agency for the
Res I io o do o 1 r c ee ha been paid./
performance of the work for which this permit is issued (Sec 3097 Civ.)
4/ L/7
Name:
Bv: Date:
PERMIT EXPIRES ON:
Address:
ate
❑ 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 19827.5 of California Health & 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 Lly a thorize a ent of the owner. I agree to comply with
all county and state laws relating to building construction. I acknowledge it is unlawful to alter the substance of an Ifici form • d cument of Butte County. I hereby
authorize representatives Butte County to en upon the above mentioned property for inspection purposes. r
/off
�!�
Print Name: L- Li Ci//�I �r- Signature:
r
Date:V�/�/
Owner ❑ Contractor ❑ Agent for Owner ❑ Agent for Contractor
l r
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATIONO
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
PERMIT NO.
BP 6 �59000
0/v-
DATE:APN:
y --
ZONING:
OWNER'S LAST NAME:
OWNER'S FIRST NAME:
PHONE:
- - a102
S ET ADDRESS:
-
FAX
CITY, ZIP:`
�J
E-MAIL:
—'
SITE ADDRESS:
J
-
CITY, ZIP• c/
b
NEAREST CROSS STREET: -
TRACT/LOT A:
APPLICANT E:
PHONE:
STREET ADDRESS:
v S
FAX:
CITY, ZIP:
gn
E-MAIL:
CONTRACTOR NAME
PHONE:
STREET ADDRESS:
- ^!
� Z `1 r (:
CITY, ZIP:
E-MAIL:E-MAI
LICENSE NUMBER: `
LICENSE TYPE:
ARCHITECT/ENGINEER NAME:
PHONE:
STREET ADDRESS:
FAX:
CITY, ZIP:
LICENSE NUMBER:
E-MAIL:
DESCRIPTION OR SCOPE OF WORK:
S 4-
❑ 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 fees will be required.
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.
For office use only:
Notes:
Application Received b : Date:
PP Y
Receipt number: Amount [Received:��