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Home My WebLink About025-320-024r I LN n Potter 4= T • !� app.2400 W.on pri.rd.(Mom's Lane), Lone Tree Rd., app.3300'S.of Paler d.,lot 3, Palermo it #4826-7%BPEM(new ingly) �. �vavQ 025-320-024. 04-2330 SAYERS, JOSEPH 54 MOMS LN, PALERMO CONT: WAIBEL A/C INC - GAS FURNACE 'T -is --6q s --6q 2 � r J r 4 r • f 2 � cn� t �+. 4826-79B�P,E,M -;P61MIT NO. f ' PERMIT EXPIRES Eddn Potter s OWNER ` owner t" cn� t �+. 4826-79B�P,E,M -;P61MIT NO. f ' PERMIT EXPIRES Eddn Potter s OWNER ` owner ffCONTR. OCATION (A.P. 25-23-64 ( NIS App.2400'W.on gri.rd.(Mom's Ln.), W/S i, Lone.Tree Rd., app.3300'S.of Palermo Rd., lot 3, Palermo i; `t a { Temp. Power Pole e Called PG&E emp Elec. Serv. — 9 Called PG&E w Temp. Gas Serv. 'y Called PG&E ' JOB FINALED (Date) (7 -Y/ (Signature) S ' ti PLUMBING--Ab-6ve Floor Permit No. 1. Water Heater--Vent--Access--Combustion Air 2. Water Pipe --Test & Anchors --Nail Protection 3. Drain Pipe--Test--Fittings & Anchors --Nail Protection 42" Test Q 4. Shower Pan --Test. First floor --Tub Access 5. Test Tub & Shower, second floor --Tub Access 6. Gas Pipe --Size & Anchors 7. Sign Job Card ................................... ALL OF ABOVE COMPLETED ,L_1 EXCEPT Signed • Date': ABOVE LISTED CORRECTIONS COMPLETED Date: a ELECTRICAL --Above Floor Permit No. - 1. Clearance & Insulation Protection at Flush Light Fixtures 2. Elec. Receptacles Spacing --Lights & Switches at Doors 3. Size Boxes & No. of Conductors --Stapled •4. Romex Installed Close to Edge of Studs & C.J. 5. Equip. Ground made up w/Mech. Fasteners 6. 2 Appliance Circuits in Kitchen & Conductor Size 7. Sub Feeders --Wire size L= ga. Cu or Al, Breaker Size Q Amp. -- Insulated NeutKal, Yes = No Q 8. Range Circuit ga. Cu or Al, Breaker Size Amp. --Oven Circuit j ga. Cu or Al, Breaker Size Amp. 9. Service --Riser Conductors & Ground 10. Bond Gas & Water Pipes 11. Clothes Closet Light --Shower Light i 12. Sign Job Card v ALL OF ABOVE COMPLETED EXCEPT Signed: Date: ABOVE LISTED CORRECTIONS COMPLETED -Date:, ...- ...... _.. ... ...... MECHANICAL --Above Floor Permit No. 1. A.C. Ducts --Insulation'& Support 2. Vent Fan --Exhaust Above Insulation 3. Condensate Drain &-Overflow--Size & Grade 4. Furnace--Vent--Access-Comb.Air--Return Air Vent --115V Outlet 5. Attic Access & Platform if Furnace in Attic 6, Sign Job Card ALL OF.ABOVE COMPLETED EXCEPT Signed: Date: ABOVE LISTED CORRECTIONS COMPLETED Date: -3- FINAL , ' Permit No. �l Plans �2 Entrance Steps, Door & Sidelight Protection Smoke Detector '4.,--',Furnace--Vents. Clearances, Combustion Air,:Connecto Garage -Height & Mech.Protection P/6. G.F.I. & Bath Fixtures Electric Trim & Sub Panel --Labels i -B _Stairs & Rails Fireplace or Stove --Clearances Hearth lectric Outlets at Wood Panel --Int. & Ext. Fixtures & Appliances in Kitchen--Grounded--Air Gap --Cooking Clearance Electrical Outlets & Receptacles at Kitchen Counter 3..Gara e Fire Door --Swing & Landing, Closer Duct in Garage --Damper 15. ater Heater --Vents, Clearances Combustion Air, P.R.V. Connector -fn Garage -Height & ch.Protection Firewalls & Openings --Area Separation Walls 17. Electrical Receptacles in Garage G.F.I. Romex protect nsulation--Foam--Looked in Attic Yes f'41,—Steps at Ext. Doors & Landings AZO., -"Guard Rails and Deck Construction X2'1. Foundation Vents &,Crawl hole Door --Drainage & Wood -Earth Clearances-- Looked Under Floor 22. Following Installed: Drive Yes ,(_1 No; Walks Yes ,L� No; !Janters or / Yes No --- Creatin D aina a Problems 7-"/ Yes No 23. A.C. --Disconnect Clearances Breaker & Conductor Size --115V Outlet ents Above Roof--Plumbin .A liances Fireplace --Clearance to Openings 5. Water Well -Disconnect, Electrical, Plumbing 26 Exterior Electrical Trim & G.F.I. Receptacle 1.4 -Ventilation Throughout House '28. Glass Protection k5l. Water Supply & Sewage Connected 32. Energy Compliance Certificate 33. Sign Job Card ABOVE LISTED CORRECTIONS COMPLETED SIGN JOB CARD Signed: Date -4- Ed' Potte_ r A t ;k rA � 0 Permit# ON INSU*--- CERTIFICATION Oroville N umberariA Street _ _ Clty County I: Subdi"'Islon Lot Number NqIIW DESCRIPTION OF INSTALLATION ROOF Material Brand Name Thickness )inches) Thermal Resistance IR Value) EXTERIOR WALL Material Fiberglass Brand Name Certaint_eed _ Thickness (inches) 3, _ Thermal Resistance (R Value) ll CEILING Batt or Blanket Type_ Fiberglass Brand Name Certainteed 611 Thickness (inches) Thermal Resistance (R Value) 19 _ Loose Fill Type Brand Name Minimum Thickness (inches) Number of bags. Weight per bag Ib Area Covered (ft2) Thermal Resistance (R Value) FLOOR,ELEVATED Material Brand Name Thickness (inches) Thermal Resistance (R Value) FLOOR, SLAB Material — Brand Name _ Thickness (inches) Thermal Resistance IR Value) Width (inches) FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance (R Value) HEATING SYSTEM Gas Furnace Make Model Description --.--�-Rated Bonnet Capacity DECLARATION 1 hereby certify that the above insulation was installed in the building at the above location ir, conformance with the current regulations setting Energy Conservation Standards for new residential buildings (located in Title 24 of the California Administrative Code). e General Contractor (Eiuilder)` License Number ±, Signal ure and Dille-�--------�—� Date % Hawk ins_.Insulation Co.- Imo. 378407 f4-ISuD Contractor (Insulation Applicator) License Number 12-6-79 $igoalure and Title Gale CERTIFICATE REVIE14ED BY _ rate BIN -029 7Builning Inspection 0£fice) P r RESIDENTIAL ENERGY CONSERVATION STANDARDS - CONSTRUCTION COMPLIANCE CERTIFICATE THIS IS TO CERTIFY THAT ENERGY CONSERVATION REQUIREMENTS HAVE BEEN INSTALL D IN CONFORMACE WITH CURRENT ENE YNSERV ION TIONS AT (1 c tign) n �1 3// BU ILD ING PERMIT NO. �� (�Y 7 A i P . NO. .G b (J THE FOLLOWING HAVE BEEN INSTALLED AS PER APPROVED PLANS: - (Check each item or write N/A if not applicable) INSULATION: Slab Edge. Fdn. Walls AtA- Floors -A IA2- Walls Ceiling/Roof Ducts Circulating Pipe APPROVED HEATER APPROVED WTR.HTR. GLAZ ING : Single Glazed Special (Insulated) CERT. & LABELED WDS. & SLIDING DRS. f/ WEATHERSTRIPPED DRS. BACK DAMPERED FANS INTERMITTENT IGNITION DEV IC,P CERT. APPLIANCES i I DECLARE THAT ALL REQUIRED ITEMS AS NOTED ABOVE HAVE BEEN INSTALLED IN ACCORDANCE WITH THE ENERGY CONSERVATION REQUIREMENTS AND AGREE TO THE COMPLETENESS OF THIS CERTIFICATE AS SUBMITTED. Insulation Applicator Name Signature of Insulation Applicator State Contractors License No. General Con tracto er N eG�/ieI (please print) Signature of General Contract Owner Date ZM State Contracto License No. THIS CERTIFICATE MUST BE ,ON FILE WITH THE BU ILD ING DEPARTMENT PRIOR TO REQUESTING FINAL INSPECTION AND SHALL BE POSTED IN A CONSPICUOUS LOCATION WITHIN THE DWELLING. COUNTY OF BUTTE — DEPARTMENT OF PUBLIC WORKS BUILDING INSPECTION RECORD BUILD Setback Forms Main Bldg. Footings Stemwa l l Slab Piers roofings Stemwall g /Z - Slab Carport C Footings Slab Patio Footings Masonry Walls Reinf. Steel Bond Beam Framing IL Stucco Mesh Scratch Brown Finish BUILDING (Cont'd) Firewall Parapets Restroom Finish Windows I/— 3� ��% R Roof Sheathir Roofing Fdn. Vents Garage Vents Insulation Prov. for ph y handicapped Conformance structure Final Footinq Heath Cool li Ducts sically ----------- of ex. FIR /z-79 1 ' FIF Soil Piping 1st Floor 2nd Floor 3rd Floor Topout Water Piping Sewer Fixtures Water Htr. Heaters Appliances Gas Piping & Temp. Gas Final Fixtun Motors Grd. Fault Pr Service Temp. Pole PLUMBING ECTRICAL 111acnvl nuiailon Permanent Door Closer Final Final MOBILEHOME UTILITIES ------------------ Elec. Service Elec. Pedestal Water Piping Sewer Gas Piping MOSILEHOME INSTALLATION - - - - - - - - - - - - - - Support Elec. Continuity Water Piping Drainage Gas Piping DATE REMARKS OR CORRECTIONS /0-�L9.-V e- 41 --N-0 fiatIp It _5-0-:-)9 0 1c Cr (NOTE: An entry must be made on this form each time you visit the job site.) COUNTY OF BUTTE - DEpARTMENT OF PUBLIC WORKS d 7 County Center Drive — Oroville, California 95965 j Tel•eptone: 534-4541 APPLICATION AND PERMIT Owner t Mailing Address /gqo� _ BUILDING / SQ. FT. OCC. I BUILDING VALUAT ` No. S AN C OSo Telephon 6z Contractor Mailing Address Fireplace �,y 2000 Total Valuation Telephone No. Permit Fee Building Addres /¢PP&,e OW Ael � Planng Fee&/or Penalty Permitit Fee Fee /00 Cn)ot,;I AMA O (VLS Or LO✓6 7 - PLUMBING No. @ FEE /1 PNO O0I Q /� fi�1� ,_., p^ /"� IGt� 1- L �7C�.� l/�/ PERMIT FILING FEE $3.00 '3-, oQ Each Trap 1,50 13,50 ,� 407— 3 P/HC,C,i�%)0 Repair drainage or vent piping 1.50 of A. P. No. 2S — �- 3— 7 oning & tanning Water piping 1.50 1,50 Each gas water heater or vent 1.50 F es W.C. S n Fire Dept. Fire Zone Use Permit Gas piping system 1 - 5 outlets 1.50 EQA Parking Parcel Plans Declaration cel 60' R/W Improvements Each additional outlet .30 Building sewer 5.00 Bldg. Plans Recd Parcel A al Plans 4Lpproval Lawn sprinkler syste 2.00 NEW ADDITION UTILITIES ❑ OTHER ❑ Permit Fee $ ELECTRICAL No. @ FEE PERMIT FILING FEE $3.00 ,Ofd Single Family Duplex ❑ Mobil Home ❑ Others ❑ 00V OR LE Main service 100 AMP ORSLESS 5.00 Main service EA. AOD'L 100 AMP 2.50 Main service OVER 100 AMPP OR LESS O 25.00 Main service EA. ADD•L 100 AMP 1.00 NEW CONST. D CUP. M OR ADDNS. ( A L 22sgft CONTRACTORS LICENSE LAW I am licensed under the provisions of Chapter 9, Div. 3, of the State of California Business & Professions Code under the name st le of: y NEW CONSTR. /MULTI BRANCH CIRCUITS) NON.RESID `BRANCH CIRCUITS) 2.50ea NEW CONSTR. POWER APPARATUS B NON-RESID. SINGLE OUTLET CIR. Ex. OCcup(OUTLETS OR FIXTIiRES 50025 Ex. OCCU // FIXED APPLNS. OR p• 1 OUTLETS (RESID.) EA) 2.00 Temporary service 110.00 Mobile Home Facilities 15.00 License No. Classification Misc. Wiring �0(4+ 6.25 �r �-. Tam exempt from the Contractors License Laws of the State of California. Permit Fee $ WORKMEN'S COMPENSATION INSURANCE I am aware of the provisions of Section3700 of the California Labor Code which requires every employer to be insured against liability for Workmen's Compensation. ❑I have placed on file with the County of Butte a certificate of Workmen's Compensation Insurance. ^fescertify 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 Workmen's Compensation Laws of Cal i forni a. I 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 County of Butte to enter upon the above-mentioned property for inspection purposes. X Dat 7 1� Signature of Permiittee or Agent Receipt No. �O Z White-D.P.W. - Yellow -Assessor - Pink -Inspector - Goldenrod -Applicant MECHANICAL No. @ FEE PERMIT FILING FEE $3.00 HeatinoUCA-P Ifl)lh 14sn t_ i Cooling Ventilation Hood 2.00 U Permit Fee $ Land Development Fee $ -2-500 TOTAL PERMIT FEE $'92 S This permit is hereby issued under the applicable provisions of the Butte County Code and/or resolutions to do work indicated above for which fees have been paid. DIRE C OR OF P IC WORKS By Date Building permit expires Date RESIDENTIAL PLAN CHECKING GUIDE (S.F., DUPLEX, & MISC. ONLY) Bldg. Permit # 2& —7 A.P. # -G V OWNER/" ` ��Gu . �, �1 i d i7"Pr A. GENERAL " 1. Zoning requirement's (sideyards and parking). 2. Valuation. 3. Signature by R.C.E. or Architect (if required). B. PLOT PLAN 1. Complete parcel size and dimensions. 2. Setbackq, sideyards, easements; etc. 3. Other buildings or structures. 4. Grading, fills, drainage. C FLOOR PLAN Complete to scale plan with dimensions. Required windows for light and ventilation (Sec. 1405).. Required windows for second exit (Sec. 1404). !' Allowable glazing for energy requirements (20% max. per.State law). Human impact glass (Sec. 5406). Required room sizes, ceiling heights (Sec. 1407). G.F.C.I.'s in baths and exterior outlets Se I-8! Ligh x ures, switches, receptacle , and exterior receptacles for maint mecnanicai equipmen . ocations o wa er heater, heating & cooling equipment other electrica_ equipment, and plumbing fixtures. J.A`*� Garage firewall, door size, and closer (Sec. 503(d)(4)). 3'0" exterior exit door (Sec. 3303d). Fireplace location. 3! Smoke detectors (Sec. 1413). D. STRUCTURAL DETAILS Foundation plan complete enough to construct building. 2- Floor construction details complete enough to construct building. �3� Elevations and wall construction details complete enough to construct Roof construction details complete enough to construct building. 'V Fireplace construction details and calcs if over one-story in height. Sufficient data and details to satisfy energy insulation requirements E. 'MISCELLANEOUS ITEMS TO LOOK OUT FOR CCX plywood on exposed locations and overhangs. Stairway details (Sec. 3305). Guardrail details (Sec. 1716). Brick or stone veneer (Chapter 30). } Exterior plaster —weep screeds (Sec. 4706 & 4708). Proper roof pitch for roof covering (Chapter 32). ,7/.' Rafter ties or bearing ridge beam. Garage door or porch header sizes. ,9.eO* Adequate bracing. 0'. Living area over garage - complete 1 -hour separation walls and posts, etc. 4i Two (2) exits on three-story dwellings (Sec. 3302). gas building. (State law). required including supporting I\ BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT 24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO) OFFICE #: (530) 538-7541 FAX#: (530)538-2140 WEBSITE: www.buttecounty.net\dds ,PERMIT NO. BP042330 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: 08/06/2004 APN: 025-320-024-000 the Business and Professions Code, and my lice{tse is in full force and effect. License Class: )+) �- License Number � Site Address: 54 MOMS LN PAL Date: —� Contractor: Map Index: Description: INSTALL GAS FURNACE 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: SAYERS JOSEPH R & MATILDA V TRUST 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 SAYERS JOSEPH &MATILDA TRUSTEES 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 54 MOMS LN she is exempt therefrom and the basis for the alleged exemption. Any OROVILLE, CA 95966 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: SAYERS JOSEPH R 8c MATILDA V TRUST 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, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). Contractor: WAIBEL AIR CONDITIONING INC ❑ 1 am Exempt under Article 3 of the Business and Professions Code Date: Owner: 1650 FEATHER RIVER BLVD OROVILLE, CA WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 95965 ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the License #: 267743 n Labor Code, for the performance of the work for which this permit 41 D//l D 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 ^ Architect: insurance carrier and policy number are: 3v Engineer: r Carrier: OFFICE COPY Policy#:L, %k, r� r/7 Z— (3uare I certify that in the performance of the work for which this permit is Total S Ft: Address Ft - q • issued, I shall not employ any person in any manner so as to Valuation: become subject to the workers' compensation laws of California. and agree that if I should become subject to the workers' Census Code: GAS compensation provisions of Section 3700 of the Labor Code, I shallMeter By Data forthwith comply with those provisions. ELECTRIC Meter By Date Date: i l9�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. 1T/ -7D CONSTRUCTION LENDING AGENCY This i is h e i s u de the ap icable provisions of the Mille County Code anrvor I hereby affirm that there is a construction lending agency for the Re o do s t do o d w h f es av een paid. performance of the work for which this permit is issued (Sec 3097 Civ.) Name: By: /n C Date. PERMIT EXPIRES [fes D Address: ON: Date ❑ 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 8 Safety Code is not applicable to the scheduled construction of this project. ❑ Attached are copies of the required E.P.A. notification forms. I hereby certify that I have read this application, that the above information is correct, and that I am the owner or the duly authorized agent of the 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. � n � Print Name: ./ 4.L Signature: Date: — C� 0 Owner Contractor ❑ Agent for Owner ❑ Agent for Contractor COUNTY OF BUTTE BUILDING DIVISION DEPARTMENT OF DEVELOPMENT SERVICES 411 Main Street - Chico, CA - (530) 891-2751 7 County Center Drive - Oroville, CA - (530) 538-7541 CORRECTION NOTICE JA OWNER PERMIT NO. A routine inspection indicates that the following violations of butte county Ordinances exist at the above address and should be corrected. Please notice this office when correction of work is completed. If you have any questions pertaining to this matter, or need additional explanation, pteas'e'co,ntact this office immediately. I --�j26U? io I- / SvlG4- r r d-1, L'I" Z-- r d /-, 'it REV 10/92 A BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT 24 HOUR INSPECTION All: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO) OFFICE M (530) 538-7541 FAX#: (530)538-2140 WEBSITE: www.buttecounty.net\dds PERMIT NO. BP042330 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: 0$/06/2004 APN: 025-320-024-000 the Business and Professions Code, and my lice{tse is in full force and effect. License Class :C)-.� )t+ j L- License Number (. Site Address: 54 MOMS LN PAL Date: Contractor: Map Index: Description: INSTALL GAS FURNACE 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: SAYERS JOSEPH R & MATILDA V TRUST 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 SAYERS JOSEPH 8c MATILDA TRUSTEES 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 54 MOMS LN she is exempt therefrom and the basis for the alleged exemption. Any OROVILLE, CA 95966 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: SAYERS JOSEPH R MATILDA V TRUST 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, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). Contractor: WAIBEL AIR CONDITIONING INC O I am Exempt under Article 3 of the Business and Professions Code Date: Owner: 1650 FEATHER RIVER BLVD OROVILLE, CA WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 95965 ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the License #: 267743 Labor Code, for the performance of the work for which this permit issued. Y mI 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 Architect: insurance carrier and policy number are: Engineer: Carrier: Policy #: ❑ 1 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 Valuation: $0.00 become subject to the workers' compensation laws of California, 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: i Zo�,�/ Applicant:Coi 4 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 Laborr— code, interest, and attorney's fees.A�f CONSTRUCTION LENDING AGENCY This i is h e i s u de the ap icable provisions of the Butte County Code ?ncVor I hereby affirm that there is.a construction lending agency for the ' Re o do s t o d w h i s av een paid. <71 -performance of the work for which this permit is issued (Sec 3097 Civ.) v.) Name: BY: c Date: 1/0Y D Address: PERMIT EXPIRES ON: Date ❑ 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 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. I hereby authorize representatives of Butte County to enter upon the above mentioned property for inspection purposes. Print Name: a—/�%�% /J Signature: //!--�l' Date: (D owner Contractor ❑ Agent for Owner ❑ Agent for Contractor