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Home My WebLink About024-100-033ARLEY MILLS �24-10-33 455 O'Brien Ave, Gridley Permit #3222-84E(ele ser ch/SF) 024-100-033 04-1871 CLARK, DAIVD . 455 O'BRIEN AVE, GRIDLEY CONT: MCCLELLAND A/C HVAC 024-100-033 04-2040 CLARK, DAVID 455 OBRIEN AVE, GRIDLEY Cont: OWNER ELE FOR SPA s. 0 OZN - lcx� 033 II q.F 4,11 --- - �- - - Y - .� _. 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 WEBw. SITE: wwbuttecounty.net\dds ' PERMIT NO. BP041871 LICENSED CONTRACTORS DECLARATION I- hereby affirm under penalty of. perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of _ Issued Date':' 06/25/200'4- APN: 024 I W1 -'000 the Business and Professions Code, and my license is in full force and- effect.rl ;1i` U� I,n2�' License Class: LC. . Licensee Number:. Site Address: 455 OBRIEN AVE GRI Date: _(0- Z< -J4 Contractor: Kc _cPQ.I�-"n-D A K Map Index: Description: NEW HVAC OWNER -BUILDER DECLARATION I hereby affirm under .penalty of perjury that I am exempt from the p 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 CLARK DAVID J &PAMELA L"ETAL Owner: _ 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'Cbntractor's State License Law (Chapter 9 commencing with Section 455 OBRIEN' AVE ' 7000) of Division 3 of the Business and Professions Code) or that he or . GRIDLEY, CA she is exempt therefrom and the basis for the alleged exemption. Any 95948-9609 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).).."_.... ❑ 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 (Sec. 7044, Business and Professions `" 'Code`'Tfie Conlracfois'`State Licerise°Law does no't apply to an" owner of property who builds or improves thereon, and who does Applicant: CLARK DAVID J &PAMELA L-ETAL_ 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 i ' year of completion, the owner -builder will have the burder bl"% proving that he or she did not build or improve for the. purpose of sale.). 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, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). Contractor: MCCLELLAND AIR CONDITIONING, INC ". ❑ I am Exempt under Article 3 of the Business and Professions Code - Date; owner: 690 THUNDERBOLT STREET CHICO, CA 95973 WORKERS' COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations:. (530) 891 _6202 13" I •Iiave and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the L r Code, for the performance of the work for whichthis permit License #: 345121 W1175issued. ' have and will maintain 'workers' 'compen'sation insurance; as' required by Section 3700 the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Architect: insurance carrier and policy number are: Engineer: Carrier:_. 0600 Policy#: —f 0 I certify that in the performance of the work for which'this "permit is Total Square Ft: 0 S. F. issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, Valuation: $0.00 and agree that if I should become subject to the workers' Census Code: compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: yp`� %� VeLL ( �� r2 q 7 Applicant: 11 c G 47W04 11 E'C`'�'Iv�C'� 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 permit is hereb issued under the applic a rovisions of the Butte County Code and/or I hereby affirm that there is a construction lending agency for the Resolution to do,. rk indicated above for hic fees have been paid. performance of the work for which this permit is issued (Sec 3097 Civ;):r Name: BY Dater PERMIT EXPIRES ON: — �.� Date Address: ❑ 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 the duly authoriz gent 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 f ny official fordocum t of Butte County. I hereby authorize representatives of Butte County to center upon the above mentioned property for inspection purpo Print Name: /T SII --C.Q/��I�T—/ Signature: Date:Y 0 ❑ Owner 0 Contractor 0 Agent for Owner gent for Contractor + 4 r . , BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT APPLICATION 24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO) OFFICE M. (530) 538-7541 PERMIT NO. DATE: APN: ZONING: NEAREST CROSS STREET: TRACTlLOTtk SITE ADDRESS: � S � � � �✓� CITY, ZIP: e I OWNER NAME-- �� PHONE: h _ g STREET ADDRESS: Ca— j p p 4� JJ 0�� IC.ti1 FAX: CITY, ZIP: I LA (Lid)APPLICANT E -MAIL: NAM4: PHONE: STREET ADDRESS: FAX: CITY, ZIP: E-MAIL: CONTRACTOR NAME: PHONE: STREET ADDRESS: FAX: CITY, ZIP: r I E-MAIL: LICENSE NUMBER u'5 LICENSE TYPE: ARCHITECT/ENGINEER NAME: PHONE: STREET ADDRESS: - FAX. CITY, ZIP:LICENSE NUMBER: EMAIL: DESCRIPTION OR SCOPE OF WORK: vi L iI Ya ❑ 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 by: Date: Amount Received: Receipt number: , j� � � q-�,/C7<11 4 (-/0 1 5 � B. C. Building Permit 01-23-04 pg 2 x Arley Mills „ Permit #3222-84 $ OFFICE COPY ` Addresses GAS Meter By Date ELECTRIC Meter By_(JAC7 Dat -Q- COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS 7 County Center Drive - Oroville, California 95965 - Telephone 916/534-4541 APPLICATION AND PERMIT PERMIT NO. ASSESSOR PARCEL NUMBER - ',r I ( )- _J -, ZONING BUILDING PERMIT OWNER TELEPHONE. -, S0. FT. OCC. BUILDING VALUATION OWNER'S MAILING ADDRESS CONTRACTOR'S NAME TELEPHONE CONTRACTOR'S MAILING ADDRESS Fireplace CONSTRUCTION LENDER UNKNOWN Total Valuation Is Filing Fee $ 10,00 LENDER'S MAILING ADDRESS Permit Fee $ ARCHITECT OR ENGINEER LICENSE NO. Plan Checking Fee $ Penalty $ ARCHITECT OR ENGINEER'S MAILING ADDRESS Permit fee $ BUILDING ADDRESS ' .� , 7 ,; IL ! r : '� .�' r/ ► _ PLUMBING PERMIT Filin Fee 10.00 9 Each Trap 2.00 Solar Water Heater 20.00 Water piping 5.00 LOT NO.SUBDIVISION NAME PARCEL MAP Each qas water heater or vent 5.00 Gas piping system 1 - 5 outlets 5.00 USE OF STRUCTURE SF'D Duplex ❑ Mobi lehome ❑ Other SPECIFY Building sewer 5.00 Mobile Home I S I G JW I 10-00e TYPE OF WORK New ❑ Addition ❑ Remo_ del Ek Utilities ❑ Installation ❑ Other ❑ Describe work: fL• �' r f' ' - ' �'� — Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 10.00 Main service 600V OR LESS 100 AMP OR LESS 10.00 , t ' Main service EA. ADD'L 100 AMP 2.50 NEW CONST. DWELLING OCCUP.& OR ADONS. ACC. BLDGS. 2/20sgft CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): ❑ I am licensed under provisions of Chapt. 9, Div. 3 of the Business and Professions Code and my license is in full force and effect. License No. Classification ❑ I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) El. I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONSTR ULTI-OUTLET 2,50 ea NON-RESID. BRANCH CIRC ITS NEW CONSTR. (POWER APPARATUS &) NON.RESID. \SINGLE OUTLET CIR. Ex. Occu 20es0a p�o OR FIXTURES 9AL®aoc FIXED APPLNS. OR FIXED A Ex. Occup. OUTLETS (RESID.) EA.) 2.00 Temporary service 10.00 Mobile Home Facilities 15.00 Misc. Wiring 15.00 -. , 1, ( 1 ' - r U ' r� . Permit Fee $ - } . L Contractor MECHANICAL PERMIT FiIingFee 10.00 WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. ❑ I shall not employ any person in any manner so as to become subject to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Heating Cooling Hood 3.00 Ventilation permit Fee $ Contractor 1 certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the Countyot Butte to enter upon the above-mentioned property for inspection purposes. 1 also agree to save, indemnify and keep harmless the County of Butte against all liabilities, judgments, costs,,and expenses which may in any way accrue against said County, in�consequence of the;granti'ng of this permit. ' X' / f Date �r r r/ Signature of Applicant — Owner❑ Contractor ❑ Agent ❑ An OSHA permit is required for excavations over 5'0" deep and demolition or construct- ion of structures over 3 stories in height. Mobile Home Installation Fee $ TOTAL PERMIT FEE $ OCCUP. GROUP I TYPE OF CONST. PARCEL PD HD ISSUE This permit is hereby issued under sions of the Butte County Code and/or work indicated above for which DIRECTOR OF PUBLIC By _ PERMIT EXPIRES Date the applicable provi- resolutions to do fees have been paid. WORKS Date ' Receipt No. -� c. `•r WHITE-D.P.W., YELLOW -ASSESSOR. PINK -INSPECTOR, GOLDENROD -APPLICANT V COUNTY OF BUTTE - DEJMENT OF PUBLIC WORKS PERMIT NO 7 County Center Drive - Oroville.j i ornia 95965 - Telephone 916/534-4541 APPLICV1 AND PERMIT ASSESSOR PARCEL NUMBER —/-0— ZONING BUILDING PERMI OWNER Rc TELEPHONE SQ.FT. OCL. BUILDING VALUA N OWNER'S MAI INGADDRE, S CONTRACTOR'S NAME A]/ TELEPHONE Al 0 CONTRACTOR'S MAILING ADDRESS Fireplace CONSTRUCTION LENDER A10 UNKNOWN Total Valuation $ Filing Fee $ 10.00 LENDER'S MAILING ADDRESS Permit Fee $ ARCHITECT OR ENGINEER LICENSE NO. Plan Checking Fee .$' Penalty $ ARCHITECT OR ENGINEER'S MAILING ADDRESS Permit fee $ BUILDING ADDRESS PLUMBING PERMIT Filing Fee 10.00 Each Trap 2.00 Solar Water Heater 20.00 Water piping 5.00 LOT NO. SUBDIVISION NAME PARCEL MAP Each qas water heater or vent 5.00 Gas piping system 1 - 5 outlets 5.00 USE OF STRUCTURE SF Duplex ❑ Mobi lehome ❑ Other SPECIFY Building sewer 5.00 Mobile Home S G W 10.00 e , TYPE OF WORK New ❑ Addition ❑ Remodel �& Utilities ❑ Installation❑ Other ❑ Describe work: lE_L_fz-OT 55 4,-yi c rz �_r,*tokj - _ Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 10.00 Main service jp0 AMP ORV OR LESS10.00 Main service EA. ADD'L too AMP 2.50 NEW CONST. DWELLING OCCUP.& OR ADDNS. ( ACC. BLDGS. 2/20sq ft CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): ❑ I am licensed under provisions of Chapt. 9, Div. 3 of the Business and Professions Code and my license is in full force and effect. License No. � Classification I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONSTR ULTI.OUTLET 2,50 ea NON-RESID BRANCH CIRC ITS NEW CONSTR. ( POWER APPARATUS &) NON-RES,D. SINGLE OUTLET CIR. 20e50C Ex. Occup(o OR FIXTURES BAL@300 PTs FIXED R Ex. Occup. OUTLETS (RESID.)EAJ 2.00 Temporary service 10.00 Mobile Home Facilities 15.00 Misc. Wiring 15.00 /5c07 ,.• Permit Fee $ Contractor MECHANICAL PERMIT FiIingFee 10.00 WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ 1 have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. I shall not employ any person in any manner so as to become subject to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Heating Cooling Hood 3.00 Ventilation permit Fee $ Contractor 1 certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the Countyot Butte to enter upon the above-mentioned property for inspection purposes. 1 also agr o save, indemni a d keep harmle s the County of Butte against all liab• i , judgme s ex es hich may in any way accrue agai s u ty i !e ant' g of this per %� Date Owner Contractor ❑ Agent ❑ Signature of Applifryuired An OSHA permit i for excavations over 5'0" deep and demolition or construct- of structures otories in height. Mobile Home Installation Fee $ TOTAL PERMIT FEE $ OCCUP. GROUP TYPE OF CONST. PARCEL PO ND ISSUE This permit is hereby issued under sions of the Butte County Code and/or work indicated above for which DIRE R OmF P LIC 4ion By PERMIT EXPIRES Date the applicable provi- resolutions to do fees have been paid. WORKS Date Receipt No. �<r%'c�, WHITE-D.P.W., YELLOW -ASSESSOR, PINK -INSPECTOR, GOLDENROD -APPLICANT 0 COUNTY OF BUTTE - DEPARTMENT PUBLIC WORKS - BUILDING DIVISION I 7 COUNTY CENTER DRIVE - OROVIL IFIRNIA 95965 - TELEPHONE: 916/534-4541 PERMIT APPLICATION DATA SHEET . r r� � Permit No. _ OWNER f2� VE /)olG -.S A. P. No. Proposed Building Use S/1 y ' Permit Fee Based Upon: Complete Contract Pricey DPW Valuation Other (Explain) Building Inspector Date_ /40—Ely At time of permit application. I was advised the following data must be submitted prior to permit processing and/or issuance`: DATE RECEIVED APPROVED 1. All items have been submitted. . . . . . . . . . . . 2. Plot plans in duplicate/triplicate. . . . . . . . . . . 3. Complete plans in duplicate/triplicate. . . . . . . . . 4. Complete engineered plans and calcs. . . . . . . . . . 5. Plans with Energy Design Compliance Statement. . . . . 6. State Energy Forms No. 7 Statement of Intent =or Non -Heated and AC Buildings. 8. Fees of $ �9. Letter of signature authorization. . . . . . . . . . . 10. Sanitation approval from Health Dept. 11. Planning approval fbr (A) Use: (B) Parking: 12. Certificate of Workmen's Compensation Insurance. . . . . . 13.- Contractor's License Information (no., name style, classif.) r14 Owner -Builder Verification (Given to owner El, Mail to owner [ ) 15. Improvements may b3 required. . . . . . . . . . . . F- Mobilehome Installa`ion Data. . . . . . .p- •Pre-Inspec. request to 17,911 Pre -Inspection for Required. Building Inspector _Q V*17', 18. Other OLO-41ulli'l-S 4 Dpw,,£.S'a •- When you issue the permit,jrocess as follows: Mail to owner. Mail to contractor. ___/Telephone �� 7� and hold for pickup at d�� office. Deliver w/inspector. Other A I icant /� 7/�/ \ /!/ /L� Date - . Copy of plans sent Healt-i Dept., Fire Dept., Other Date During the plan checking process, the following data must be submitted prior to permit issuance: (For required items not checked above at time of application, circle item.) 1. Index permit for above Items No. 2. Additional items required: (Contractor, Designer, Owner) was advised of above required data by Telephone Mail Other By Date Plans checked by. Plans approved by Other Copy—DPW Date Date V.. 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.nehdds PERMIT NO. BP042040 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' 07/12/2004 APN: 024-100033-000 ' the Business and Professions Code, and my license is in full force and effect. License Class: License Number: Site Address: 455 OBRIEN AVE GRI Date: Contractor: Map Index: OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Description: ELECTRICAL FOR SPA 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' CLARK DAVID J & PAMELA L ETAL 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 455 OBRIEN AVE 7000) of Division 3 of the Business and Professions Code) or that he or GRIDLEY, CA 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 95948-9609 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 Applicant: CLARK DAVID J & PAMELA L ETAL 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 455 OBRIEN AVE year of completion, the owner -builder will have the burden of GRIDLEY, CA proving that he or she did not build or improve for the purpose of sale.). 95948-9609 ❑ 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, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). Contractor: O lam Exempt under Article 3 of the us' s Professions Code -12---d Date: Owner. WORKERS'COMPENSAT16N 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 License #: 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 Architect: the work for which this permit is issued. My workers' compensation Engineer: 9 insurance carrier and policy number are: Cartier: Total Square Ft: 0 S. F. Policy #: I certify that in the performance of the work for which this permit is Valuation: $0.00 issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, Census Code: 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. � % 2— V 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 4.0&-0:,9 compensation, damages as provided for in Section 3706 of the Labor code, interest, and attorney's fees. CONSTRUCTION LENDING AGENCY This permit is hereby issued under the applicable provisions of the Bette County Code anevor I hereby affirm that there is a construction lending agency for the ResolutionZod work indicated above for which fees have been paid. performance of the work for which this permit is issued (Sec 3097 Civ.) '7*f 2 O Name: By: ^ — Date: PERMIT E RES ON: 7' I S Address: Date ❑ 1 hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage, handling and use of hazardous materials. ❑ Notification in accordance with Section 19827.5 of California Health & Safety Code is not applicable to the scheduled construction of this project. Cl 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 county and state laws relating to building construction. I acknowledge it is unlawful to alter the substance of y offic' I f o ument of Butte County. 1 hereby authorize representatives of Butte County to enter` th above mentioned property for inspection purpose Gon ; �Ll�/ Print Name: �>�(/l [/I"i" Signature: Date: Owner 0 Contractor ❑ Agent for Owner 0 Agent for Contractor BUTTE COUNTY o DEPARTMENT OF DEVELOPMENT SERVICES 0 BUILDING PERMIT APPLICATION 0 AND SUBMITTAL REQUIREMENTS 0 24 HOUR INSPECTION#: OROVILLE: (530) 538-7636 • CHICO: (530) 891-2834 00 OFFICE #: (530) 538-7541 A FEE WILL BE REQUIRED AT TIME OF APPLICATION "PLEASE PRINT CLEARLY" APPLICANT SIGNATURE X For office use only: OWNER Last Name C10-1-kirst Flood Zone Nam a 1// Address-- ,� I/ C City ` State Sta Zip PhonE�1�.,� Fax Fat ^ �� E-mail Uc. # APPLICANT SIGNATURE X For office use only: CONTRACTOR Name Flood Zone Address SRA City I No State Zip Phone 2.� Fax E-mail Planner Uc. # Class APPLICANT SIGNATURE X For office use only: ARCHITECT/ENGINEER Name Flood Zone Address SRA City I No State Zip Phone 2.� Fax E-mail Planner State Ucense Number APPLICANT SIGNATURE X For office use only: APPLICANT NAME Name av Flood Zone Address SRA City j' Vim^ r I No S n Z Phon-/ , 2.� �'C, l Fa�� i� ' b E-mail Planner APPLICANT SIGNATURE X For office use only: Zoning Pr�dress Flood Zone Cross Street/ L�"tt� SRA I Yes I No Occ. Type Const. Subdivision Name Map Book Page Lot # Planner Date Approved: PERMIT NO. BP o4 BIN # LOCATION AP# ��4 • I oo • 033 Pr�dress C Cross Street/ L�"tt� 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: ELEt2, Fa S P Sq. Footage ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): f EXPIRATION OF APPLICATION Applications for which a permit has not been issued will expire one year after the date of application. In order to renew action on an application after expiration, a new application, plans and fee will be REQUEST FOR REFUNDS Refunds can only be made upon written request by the person who paid the fee. The request must be made prior to the expiration of the permit and no construction work has been done. Filing fees, plan check fees for work plan checked and other department costs are not refundable. OVER FOR SUBMITTAL REQUIREMENTS L K:\FORMSMILDING F0RMS\B1dgApp1SubRgmts.doc Page 1 of 2 Received by: leM`' Amount: 55._ Bldg Receipt #: c# ��o::j Date: 7. 1,_n. 0 + SRA Sheriff SMIP Other 55 •^ Total REV 6-16-04 SUBMITTAL REQUIREMENTS The following drawings and specifications must be submitted to the Building Division in order to apply fora permit. INCOMPLETE SUBMITTALS WILL NOT BE ACCEPTED. ALL PLANS MUST BE LEGIBLE AND IN IN% Residential, New, Remodels, Additions, and Accessory Structures: ❑ 1. 3 Site Plans, signed by the preparer. NO GRAPH PAPER! ❑ 2. 3 Complete sets of plans, signed by the preparer. NO GRAPHPAPER! OR 3 Sets Engineered plans (if required) with wet signature onplans AND 2 sets of stamped and signed calculations. ❑ 3. 2 Engineered truss details and layouts (if required) (NO FAXES!). '❑ 4. Letter from Engineer or Architect for truss design review. ❑ 5. 2 Energy compliance design and supporting documentation. (Note: Not required for additions to mobile or modular homes.) ❑ 6. 2 Flood Elevation Certificate, wet -stamped and signed (if required). ❑ 7. Detached Accessory Building Form, filled out by the property owner (if required). ❑ 8. Sanitation and site plan approval from the Environmental Health Department. ❑ 9. Metal Buildings: (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. Mobile, Manufactured, or Modular Homes: ❑ 1. 3 Site Plans, signed by the preparer. NO GRAPHPAPER! ❑ 2. 2 Data sheets and installation instruction manual. ❑ 3. 2 Marriage line information. ❑ 4. 2 Floor plans. , ❑ 5. 2 Engineered Tie Downs or Foundation plans. ❑ 6. Sanitation and site plan approval from the Environmental Health Department. ❑ 7. 2 Flood Elevation Certificate, wet -stamped and signed (if required). Commercial, New, Additions and Remodels: ❑ 1. 4 Site Plans, signed by the preparer. NO GRAPH PAPER! ❑ 2. 4 Engineered plans with wet signature on plans AND 2 sets of stamped and signed calculations, with code analysis. ❑ 3. 2 Engineered truss details and layouts (if required) (NO FAXES!). ❑ 4. Letter from Engineer or Architect for truss design review. ❑ 5. 2 Energy compliance design and supporting documentation (if required). ❑ 6. 2 Flood Elevation Certificate, wet -stamped and signed (if required). ❑ 7. Statement of Intent for Non -heated and A/C (if required). ❑ 8. Metal Buildings: (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. ❑ 9. Letter of intent. ❑ 10. Hazardous Material Form. ❑ 11. Sanitation and site plan approval from the Environmental Health Department. If you have questions or would like additional information regarding this process, contact a Permit Application Assistant at (530) 538-7541. OVER FOR BUILDING PERMIT APPLICATION KAFORMSWILDING F0RMS1BIdgApp1SubRgmts.doc Page 2 of 2 REV 6-16-04 O.L.- 1 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. ti. I personally plan to provide the major labor and materials for construction of the proposed property improvement : YES g NO ❑ 2: I HAVE 'E3 HAVE NOT ❑ signed an application for a building pemmit for the proposed work I have confragfpdwi the f ll g person (firm) to provide the proposed construction: NAME: �z v� GAG' ADDRESS: CITY:(� PHONE: Z CONTRACTOR'S LICENSE NO. 4. I plan to provide portions of this work, but I have hired the following person to coordinate, supervise, and provide the major work NAME: ADDRESS: CITY: PHONE: CONTRACTOR'S LICENSE NO. S. 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 SIGNED: PROPERTYOWNER:A// � O� 4DAT'E: NOTE: This Owner -Builder Verification is required by Section 19831 and 19832 of the California Health and Safefy Code. This verfication , must be completed and returned to our office before we are permitted to issue the permit w OWNER BLILDFR INFORMATION Dear Property Owner. O. . — An application for a building permit has been submitted in you name listing yourself as the bmlder of property improvements specified. For yourpmtection, You should be aware that as "owner -builder" you are the responsible party ofrecord on such a pew Building permits are not required to be signed by Property owums wnless they are personally performing their own work- If your work is being performed by someone other than yourself You may Pmt YOM-selffrompossible liability if that person applies for time 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 li apply.• cense number on all permits for which they If You pilar to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection. 0 Ifyou employ or of m w be engage any Persons other than your immediate family, and the work (=chiding materials and other costs) is $300 or more for the entire project; and such persons are not licensed as contractors or subcontractors, then You may be as employer, ♦ If you are an employer, you Must register with the State and Federal Govemments as an employer and you are subject to workers con venal ion masuons including fed state and federal 111003310 tEx withholding, federal social security taxes, disability msmm= costs, and unemploymag compensation contributions. a There may be financial risks for you if you do not cagy out these obligations, and these risks are with ed to worimes compensation scour �P lifcnrarrp ♦ For more specific information about your obligations under Federal Law, contract the fidF--rn;1 RoVeMie, Service (and, if yon wish, the U.S. Small Business Administration). For mare specific fi&rmation about your obligations under State Law, contact the Departrn= of BeneSt Payments and the Division of Industrial Accidents. If the stivct=e is intended for sale, Property owners who are not licensed contractors are allowed to perfoan their work personally or through their own employees, without a liceased contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons Prolhssing to be contractors is to secure an '*owner bundea" building Pew. Wmevusly implying that time property owns is providing his or her own labor and material permits are not required to be signed by property owners unless they are Pig their own work � Building Infa»iion about licensed =Amtors may be obtained by contracting the C�actOrs State License Booa d n your commrmity or at 1020 N Street, SammnentO, CA. 95814. Please complete the "Owner Builder Veaificatian" on time reverse side of this form so that we can confirm that you are aware of these matteaL The buridmg p== WM not be issued unta the verification is returned. NOTz. This Owner -Bum Infonr:a:fon is required by Section 19830 oftie CaWonda Heah* and Safety Code