HomeMy WebLinkAbout039-470-021%3T�'�.
BUTTE COUNTY
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DEPARTMENT OF DEVELOPMENT SERVICES
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BUILDING PERMIT APPLICATION
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AND SUBMITTAL REQUIREMENTS
a p
24 HOUR INSPECTION#: OROVILLE: (530) 538-7636 • CHICO: (530) 891-2834
Phone 3L4- —l�O
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OFFICE #: (530) 538-7541
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A FEE WILL BE REQUIRED AT TIME OFAPPLICATION
Website:—www.buttecounty.net/dds
Class
**PLEASE PRINT CLEARLY"*
OWNER
CONTRACTOR
Last Name
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F t Name (1� 4-
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Address -7
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City Ch
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Sta
CA I
Zip (,9q1j3
Phone 3L4- —l�O
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Fax
Fax
E-mail
APPLICANT NAME
CONTRACTOR
Name nCn 6L
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Address`Po
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City 4
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State C l
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Zip
Phone .3� 14
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Fax
E-mail
Lic. # -1
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Class
APPLICANT NAME
ARCHITECT/ENGINEER
Name
State/ rt
Address
g
City
P
State
Zip
Phone
Lot #
Fax
E-mail
State License Number
APPLICANT NAME
Name C f t. Vfl
Address P6 .I 3s -
JCity
City i (� b i n b s
State/ rt
Zip
g
Fax'ajA
P
For office use only:
Zoning
I Flood Zone
SRA
Yes
No
Occ.
Type Const.
Subdivision Name
Map Book
Page
Lot #
Planner
Date Approved:
OVER FOR SUBMITTAL RECRUIRtMtN 15
K:\FORMS\BUILDING FORMS\BldgApplSubRgmts.doc
PERMIT
NO.
o'-5'2
BIN #
LOCATION
AP# O Sq 14 -7o o Q- I
Property Address
City
Cross Street
WORKER'S COMPENSATION
Policy Number S-5 — @) D
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 orff__Scope of Work:
T
o
Sq. Footage
❑ 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
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.
Page 1 of 2
Received by: Amount:
Gem.
Receipt #:j iJ )
L� 7
SRA
Sheriff
SMIP
Other
Total
REV Z 24-05
I
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 BEACCEPTED. ALL PLANS MUST BE LEGIBLEAND 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 inst, (B) Marriage line info, (C) floor Plan, (D) Tie down or fnd plans, all in
duplicate.
❑ T. 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. Detached Accessory Building Form filled out by the owner (if required).
❑ 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. ❑ Grant Deed, ❑ M.H. Title/Statement of Facts.
❑ 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
KAFORMSSUILDING F0RMS\BIdgApp1SubRgmts.doc Page 2 of 2 REV 2-24-05
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE M (530) 538-7541 .
PERMITSBECOME NULL AND VOID 1 YEAR FROM THE DATE
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
the Business and Professions Code, and my license is in full force and
effect./ -�1 O
License Class :C.o�G C 38 License NumrbeQr,7`77 33
Date:' Contractor: C-4([AgC.,evS TfUF}C.
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
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 the Business and Professions Code
Date: Owner:
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.
CP--' 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:
Policy #:
❑ 1 certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to
become subject to 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
fortthhwith) comp)y with those provisions.
Date: 1 1
Applican .
WARNING ailure to sec re workers' compensation coverage is
unlawful, a hall 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
performance of the work for which this permit is issued (Sec 3097 Civ.)
Name:
Address:
PERMIT NO.
I:101*z1 tii
OR IF WORK IS DONE IN VIOLATION OF ANY COUNTY OR STATE LAWS. .
Issued Date: 09/14/2005 APN: 039-470-021-000
Site Address: 3776 RODGERS AVE CHI
Map Index:
Description: HVAC REPLACE
Owner: WRIGHT ARTHUR R & ANITA L
3776 RODGERS AVE
CHICO, CA
95928
Applicant: GALLAGHER'S HEATING & AIR
PO BOX 35
LOS MOLINAS, CA 96055
800-892-3556
Contractor: GALLAGHER'S HEATING & AIR
PO BOX 35
LOS MOLINAS, CA 96055
800-892-3556
License #: 777334
Architect:
Engineer:
Total Square Ft: 0 S. F.
Valuation: $0.00
Census Code:
6�
I�
This permit is reby issy andthe applicable provisions of the Butte County Code and/or
Resolutions o do w li
SPECIAL CONDITIONS
CHECKED
BY
SRA
FLOOD CERTIFICATE REQ. ,
FIRE SPRINKLERS REQ.
SPECIAL INSPECTION ITEMS
1
VERIFY
USE PERMIT CONDITIONS
,SUB -STANDARD HOUSING LETTER
1
c� v
;JOB
FINALED Da '
J=OK
o =Not OK
= Not R,,e
. =Not Ready eaQy
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/O -Concrete
4. Water Location -Test -Easement Needed (Sketch)
5. Electricity, Location -Clearances -Grad-/ , /Amp -Concrete
6. Gas; Location-Test-Wrap;4 - : P L'ft-;:
/ i' Nat or'/'.'. P L -A./ .: P LPG .
7. Well Clearance & Disconnect
8. IJtil-ity Clearance -
10. Roof•, Shthg-Roofing -- , . i , ° •
11: Ext; Steps -Doors -Landings . `
Date
Card B-1 Date Card B-1
Date
Card B-1 ;Oate Card B-1
Date
MOBILE HOME INSTALLATION (Plans) OK except Ifs
Date
1., Zoning Requiremerits-Setbacks_Easements
Date
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-Connectot
7. Water and Sewer Connected -C/O to Grade -HD Approval
8. Gas and Electricity Tagged
9. Tie Downs -Type -Installation CerL
10. Exits; Insp.-Sketch
11. Cert of Occupancy
10.- Plumb.; Cir. Test -Water Supply. Tom.. ...:. :: •
11.._Light Niche =
Date
Card B-1 Date Card B-1
Date
:Card 6-1 Date .. .. .... :..Card B-1
Date
PERMANENT END SYSTEM (ONLY)
Date ......
1. Zoning Requirements -Setbacks -Easements
2. Footings; S¢i:-Spacing_` ..• Triage Line "-` .: .
3 Blod6'g
f
4.'- Gas; MH Test=Demarid_Valve ` .:. ..
5. Electricity; MH Test
6. Water, MH Test ::.:..
7.. Water. and Sewef _Connected .
8. Gas and EledddtyTayged' -
' 10.: License Decals'
11. Verify.A's with Office '.:
Date
Cam B-1 Date' - `.Card 6-1.
Date.
Cana B-1 . Date Card B-1
0.
MISCELLANEOUS
Date
DECKS, COVERS, CARPORTS, GARAGES (Plans) OK except 9's
1. Zoning Requirements -Setbacks -Easements
2. Footings; Soils -Size -Depth -Spacing -Connectors -Steel
3. Decks; Girders and/or Joists -Decking -Bracing -Stars -Rails
4. 'Wood Awn.; Posts-Beams-Rftrs-Connectors
Shthg-Frg-Bracing
5.- Alum. Awn.; Columns-Connections-Splice-Decal�Enclosures
6.: Carports; Windows -Doors
.J. Electric
8. Frmg.; Sills-Anchors-Studs-Mrs-Tnisses
9. Siding; Nailing -Veneer -Stucco -Mesh
10. Roof•, Shthg-Roofing -- , . i , ° •
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 9'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
S. Elec.; Pool Lighting; 15 Vons-GFI
6. Sec.; Enclosures; Conduit Entries -Terminals. -Listed
7. Elec.; Bonding; Metal w/5' -Circulating Equip: Heater
8. Elea; Grounding; EGuiP. w/5' Ciiirulating Equip. -Pool Lghtg.
Boxes-Enclosures-Panelboards-Ins. to Main Conduit
9: Health Department Approval
10.- Plumb.; Cir. Test -Water Supply. Tom.. ...:. :: •
11.._Light Niche =
12. Enclosure; Fencing -Alarms
Date...._ ...:
:Card B-1 ... Date Card B-1
Date ......
Card B-1 '...:: .:` Date .. .='.: :. `' '. Card B-1
OK
Not OK
Not Appfiable
N6t Ready
RESIDENTIAL (Single & Duplex)
tte UNDERFLOOR (Plans) OK except O's
1. Zoning -Setbacks -Easements -Flood -Slope
2. Ftg., Main; Sols-Elec. Gmd.-/ . r Ftg. Depth
3. Ftg., Garage; Sols-Steel-Elec. Gmd.-/ P Ftg. Depth
4. Ftg., Porches & Decks; Soils -Steel-/ P Ftg. Depth
S. Stemwalls, Main; Steel-Blockouts-Wrapped
6. Stemwalls, Garage; Steel-Blockouts-Wrapped
6a. Hold Downs and Special Anchors
7. Slab, Steel -Wrapped
8. Piers -Fireplace Ftg.-Steel
9. D.W.V.; Fall -Felting -Test -2 Way C/O -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 BOIts-Joists-Vents-Crippies
15. Access & Ventilation
16. Insulation .
late
Card B-1 Date Card B-1
)ate
Card B-1 Date Card B-1
)ate
PLUMBING (Permit) OK except R's
17. Water Htr.; Vent -Access -Combustion Air Baffle
18. Water Pipe; Test & Anchor -Nal Protection
19. D.W.V.; Test Fittings & Anchor -Nal Protection
20. Shower Pan; Test. First Floor -Tub Access
21. Test Tub & Shower, Second Floor -Tub Access
22. Gas Pipe; Sixe & Anchors
23. Fire Sprinkler, Test
73. IGL Fixt. & Appliance; Ground -Air -Gap -Cooking Clearance
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Cana RA
Date
ELECTRICAL (Permit) OK except Vs
24. Fixture & Transformer Clearance -Ins. Protection
25. Elec. Receptacles Spacing -lights & Switches at Doors
26. Site 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 Al -AC. Wire Size/ /ga Cu or AI
31. Range Circle/ /ga Cu or Al -Oven Circ. / /ga Cu or AI
Insulated Neutral 0 Yes 0 No
32. Service -Riser Conductors & Ground Main Disconnect
33. Equip. Clearances Panels -Motors -Meth. Equip.
34. Clothes Closet Light -Shower Light -Spa Light
35. Smoke Detector
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
Date MECHANICAL (Permit) OK except Vs
36. A.C. Ducts Insulation & Support
37. Vent Fan, Exhaust above insulation
38. Condensate Drain & Overflow, Size & Grade
39. Fumace-Vent Access -Comb. Ait-Retum Air Vent 115 Outlet
40. Attic Access & Platform if Furnace in Attic
Date Card B-1 Date Card B-1
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. Fre Stops, Furred Ceilings -Stairs -Chasers -Tubs
46. Headers & Beams -Size & Bearino
Date FRAMING (Continued)
47. Hangers -Post Caps -Anchors -Connectors
48. Cling. Joist-Rftr. Ties-Pudin-Roff Brac_ Truss-Shting= Rtng.
49. Fireplace Ties or Type A Flue-F'ireplade Throat Clearance
50. Attic Access; Size & Romex Protection -Draft Stop -Ins. Baffles
51. Bdmt. Windows or Exiting Doors -Sill Ht & Dimensions
52. Garage Fre Protection Framing -RC Channel
53. Property Line Firewall & Openings
54. ExL Doors -One T -Check Garage 3rd Story, 2 Exits
55. Stairs; Width -Headroom -Rise -Run -Landing -Fre Protection
56. Plywood on Roof Overhang -Attic Vents -Rafter Outriggers
57. Siding -Nailing Veneer
58. Stucco Mesh -Drip Screed -Fd. Verits-Undertir. Access
59. Glazing Area -Glass Protection -Skylights -Plastic
60. Shear Walls; Nairing-Bolts
61. Brace Interior/Exterior Wall Panels
62. Insulation-Walls-Celings
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 & Rads
71. Fireplace or Stove, Clearance -Hearth
72. Elec. Outlets at Wood Panel, Int & Ext
73. IGL Fixt. & Appliance; Ground -Air -Gap -Cooking Clearance
74. Elec. Outlets & Receptacles at Kit Counter
75. Garage Fre Door, Swing -landing -Closure
76. A.C. Dud in Garage -Damper,
77. Wtr. Htr.; Vents -Clearance -Comb. Air Connector-P.R.V.
in Garage; Above Floor -Meth. Protection
78. Plb.; Elec. & Medi. Equip: Listed for Location
79. Elec. Receptacles in Garage (FF.I.)-Romex Protection
80. Insulation-Fdam-Looked in Attic
81. Guard Rails & Deck Construction -Post Caps
82. Fdn. VBents & Crawl Hole Door Drainage & Wood -Earth
Clearance Looked under Floor 0 Yes
83. Following tnsUdJDrive 0 Yes 0 No/Walks 0 Yes 0 Nw?lantm 0 Yes O No
84. Stucco 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 Dec. Trim, G.F.I. Receptacle -Underground
89. Ventilation Throughout House
90. Glass Protection
91. Corrections from Previous Inspections
92. Gas Test -Meters Tagged, Gas-Sectric
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:
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.
BP052475
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
Issued Date: 09/14/2005 APN: 039-470-021-000
provisions of Chapter 9 (commencing with Section 7000) of Division 3 of
the Business and Professions Code• and my license is in full force and
effect•fr
License Class :`�U L 38 License Number:717 3 `3 i-
Site Address: 3776 RODGERS AVE CHI
��
Date: 1 ,- Contractor:6�6l 161 %_C&_.; {f v A
Map Index:
Description: HVAC REPLACE
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: WRIGHT ARTHUR R & ANITA L
permit to construct, alter, improve, demolish, or repair any structure, prior
3776 RODGERS AVE
to its issuance, also requires the applicant for such permit to file a
CHICO, CA
signed statement that he or she is licensed pursuant to the provisions of
the Contractor's State License Law (Chapter 9 commencing with Section
95928
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
Applicant: GALLAGHER'S HEATING & AIR
Code: The Contractors' State License Law does not apply to an
PO BOX 35
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
LOS MOLINAS, CA 96055
sale. If however, the building or improvements are sold within one
800-892-3556
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.).
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
Contractor: GALLAGHER'S HEATING & AIR
not apply to an owner of property who builds or improves thereon,
PO BOX 35
and who contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
LOS MOLINAS, CA 96055
❑ 1 am Exempt under Article 3 of the Business and Professions Code
800-892-3556
Date: owner:
License #: 777334
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
Architect:
Labor Code, for.the performance of the work for which this permit
is issued.
Engineer:
I❑� 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.
Valuation: $0.00
11-L1rYld
Policy#: I)�J(� �'� .
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
r�
become subject to the workers' compensation laws of California,
(l1J
and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comp)y with those provisions.
7
Date:
V
Applican .
WARNING ailure to sec re workers' compensation coverage is
unlawful, a hall 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 permitis reby issy and the ap licable provisions of the Butte County Code and/or
Resolutions
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec 3097 Civ.)
o do w ruin icated bove r which fees have been paid.
Name:
By: Date:
PERMIT EXPIRES ON:
(Date)
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.
❑ 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 stance of any offici I form or document of Butte County. I hereby
authorize representatives of Butte County to enter upon the above mentioned property for inspec'on rposes.
� r\ l Tom'' C-, r uh �I-- A 19
Print Name::r Signatu
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Q Owner O Contractor ❑ Agent for Owner 49 Agent for Contractor