HomeMy WebLinkAbout025-320-025BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541 FAM (530)538-2140
WEBSITE: www.buttecounty.net\dds
PERMIT NO.
BP043160
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: APN: 025-320-026-000
the Business and Professions Code, and my license is in full force and
effect.
License Class: License Number: C /
Site Address: 962 LONE TREE RD PAL
Date:/ —0 -d Contractor: vte4
Map Index:
Description: reroof (27)
OWNER -BUILDER DECLARATION
1 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: IVERSON FREDRICK L 8r PATRICIA S
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
962 LONE TREE RD
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
OROVILLE, CA
she is exempt therefrom and the basis for the alleged exemption. Any
95965
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: GEORGE ROOFING
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
6810 LINCOLN BLVD
sale. If however, the building or improvements are sold within one
year of completion, the owner -builder will have the burden of
OROVILLE, CA 95966
proving that he or she did not build or improve for the purpose of
(530) 533-6393
sale.).
❑ 1, 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
Contractor: GEORGE ROOFING
pursuant to the Contractors' State License Law.).
❑ 1 am Exempt under Article 3 of the Business and Professions Code
6810 LINCOLN BLVD
OROVILLE, CA 95966
Date: Owner:
(530) 533-6393
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
License #: 452266
❑ 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.
I have and will maintain workers' compensation insurance, as
Architect:
Engineer:
9
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: -TL
Total Square Ft: 0 S. F.
Policy #:_ .179
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.
Date: % 0 — o -Z —d
/
Applicant: 9gt:LJWe,
_
WARNING: Failure to secure workers' con nsation 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 s provided for in Section 3706 of the Labor
code, interest, and attorney's fees.
CONSTRUCTION LENDING LENDING AGENCY
This permit 0,bereqy issued under the applicable provisions of the Birfte County Cods anti/or
I,.he[eby affirm that thereisa construction-lendingagercy focthe— - .
performance of the work for which this permit is issued (Sec 3097 Civ.)
.Resolutions ork indicated above for which fees havebeenpaid.
f U• 6 _
Name:
,
By Date: ��� [[[ II
Gev, G
Address:
PERMIT EXPIRES q •
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.
❑ Attached are copies of the required E.P.A. notification forms.
1 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 any official form or document of Butte County. 1 hereby
authorize representatives of Butte County to enter upon the above mentioned property for inspection purposes.
Print Name:
v�CiSignature:
Date:
*Agent
❑ Owner ❑ Contractor for Owner ❑ Agent for Contractor
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATION
AND SUBMITTAL REQUIREMENTS
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
A FEE WILL BE REQUIRED AT TIME OF APPLICATION
APPLICANT SIGNATURE
X Shirley Trew - Agent for George Roofing
For office use only:
OWNER
Name
Fred Iverson & Debra Engler
Address
962 Lone Tree Rd.
City
Oroville
State CA
Zip 95966
Phone
916-853-5923
Fax
E-mail
Lic.#
APPLICANT SIGNATURE
X Shirley Trew - Agent for George Roofing
For office use only:
CONTRACTOR
Name
GEORGE ROOFING
Address
6810 Lincoln Blvd
City
Oroville
State CA Zip
Phone
(530)533-6393
Fax (530)533-0287
E-mail
dan@abcgc.com
Lic.#
Class
dan@abcgc.com
452266
1 C39
APPLICANT SIGNATURE
X Shirley Trew - Agent for George Roofing
For office use only:
ARCHITECT/ENGINEER
Name
N/A
Address
6810 Linocln Blvd
City
Oroville
State CA Zip
Phone
(530) 533-6393
Fax
E-mail
dan@abcgc.com
State License Number
APPLICANT SIGNATURE
X Shirley Trew - Agent for George Roofing
For office use only:
APPLICANT NAME
Name
GEORGE ROOFING
Address
6810 Linocln Blvd
City
Oroville
State CA Zip 95966
Phone
(530) 533-6393
Fax (530)533-0287
E-mail
dan@abcgc.com
APPLICANT SIGNATURE
X Shirley Trew - Agent for George Roofing
For office use only:
Zoning Flood Zone SRA Yes No
Occ.
Type Const.
Subdivision Name
Map Book
Page
Lot #
Planner
Date Approved:
PERMIT NO.
NO.
BP0LI5M0
BIN #
LOCATION
AP# 025-- e 7 9 —
Property Address 962 Lone Tree Rd.
Oroville,Ca. 95966
Cross Street
WORKER'S COMPENSATION
Policy Number 272-596-02
Carrier STATE FUND
If hiring anyone other than license contractors, a certificate of workers
compensation must be shown at the time of permit issuance.
LENDING AGENCY
Name
Address
Description or Scope of Work
Reroof - House - Comp
Sq. Footage 27 Squares
❑ 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:17
�P
? _kN v YZ R
Receipt #:
Bldg
SRA
Sheriff
SMIP
Other
Date: Ib/2 0/1 `/ , Total
' / REV: George Roofing