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CO ,,. OF BUS - DEPARTMENT OF DEVELOPMENT SERVICES - BUILDING DIVISION
7 Count, -enter Drive Oroville, California 95965 • Telephone (530) 538-754��jj �,EXMIT No.
(Rev.12/96) ,' APPLICATION AND PERMIT
ASSESSOR PARCEL h.._
VARTOTIS ';FR ATTACHED
ZONING
BUILDING PERMIT
OWNER
TELEPHONE
SO_ Fr. OCC. BUILDING VALUATION
OWNERS MAILING ADDRESS
4190 PFTJ DR, SACRAME= 95838
CONTRACTOR'S NAME
WESTCOAST MH
TELEPHONE
-343-9473
CONTRACTORS MAILING ADDRESS
140 MEMS ST CHICO 95928 -
CONSTRUCTION LENDER
LENDER'S MAILING ADDRESS
Fireplace
Total Valuation $
ARCHITECT OR ENGINEER
LICENSE NO.
—.Filing Fee $
20.00
Permit Fee $
ARCHRECT OR ENGINEERS MAILING ADDRESS
Plan Checking Fee $
BUILDING ADDRESS
ATTACHED
Energy Plan Checking Fee $
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PERMIT FEE $
LOT NO.
SUBDIVISION'S NAME
PARCEL MAP
PLUMBING PERMIT
Filing Fee 20.00
USEOFSTRUCTURE
SF ❑ Duplex ❑ Mobilehome ❑ Other
SPECIFY
Each Trap
7.00
Solar or heat pump water heater
23.00
Water piping
15.00
Each gas water heater or vent
15.00
TYPE OF WORK
New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other ❑
Describe Work: PLACE CATV POWER SUPPLY
Gas piping system 1 - 5 outlets
15.00
Building sewer
15.00
Mobile Home I S I G I W
@20.00
PERMIT FEE $
ELECTRICAL PERMIT
Filing Fee 20.00
Main Service zoOA OR LESS 5
23.00 345.0
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 (commencingwith Section 7000 of Division 3 of the Business and Professions Code,
)
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and my license is inAll force and effect -76S
License Class — Lic. No. / !
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors License
Law for the following reason:
❑ 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.
❑ I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project.
❑ 1 am exempt under Sec. Business and Professions Code for this
reason
WORKERS' COMPENSATION DECLARATION
1 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 of the Labor Code, for the performance of work for which this permit is issued.
My workers' compensation insurance carrier and policy number are:
Carrier
Policy Number
(The above sections need not be completed If the permit is for work of a valuation
of one hundred dollars ($100) or less.)
❑ 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 workers'
compensation laws of California, and agree that if I should become subject to the
worker ' c pensati n isions of section 3700 of the Labor Code, I shall
forth Ith co ply o rovisions.
X Date
Signature of Applicant - ❑ Owner Contractor ❑ Agent
An OSHA permit is required for excavations over 5'0" deep and demolition or construction
of structures over 3 stories in hei ht.
Main Service 200A TO 1000A 46.00
NEW CONST. DWELLINGOCCUP. s0
OR ADDNS. ( a ACC. BIOS, 3.5dFT:
NEN co MULTI•ounUr
NON-RESID. �%O 7.50
�R,wPARA
a sINGLE OUTLET Al
00
Ex. Occup. OUTLET OR FOCTUREs SAL 0 .50
Ex. Occu . oLirttDTS�Es o.oFR.a 5.00
Temporary Service 23.00
Mobile Home Facilities 20.00
Misc. Wiring 23.00
PERMIT FEE S 365.00
MECHANICAL PERMIT Filing Fee 20.00
Heating
Cooling
Hood 6.50
Ventilation
PERMIT FEE S
Mobile Home Installation Fee $
Energy Inspection Fee $
Occ
CONST. TYPE
TOTAL FEE $ 365.00
KAZ. I D FEES IMP FLOOD CDF PARCEL PO HD
SUE
This permit is hereby issued under the applicable
of the Butte County Code and/or Resolutions
indicated above for which fees have been
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B ate
PERMIT EXPIRES ON
Dn
provisions
to do work
paid.
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ReceiptNo. 7757
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