HomeMy WebLinkAbout042-630-013to
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sOUTTFe Butte County Department of Development Services
PERMIT CENTER
7 County Center Drive, Oroville, CA 95965
c� NZy Main Phone (530)538-7601 Permit Center Phone (530)538-6861 Fax(530)538-2140
AFFIDAVIT REQUESTING DUPLICATE PLANS
(California Health and Safety Code Section 19851-19853)
FORM NO
The official copy of the building plans may not be duplicated without written aermission from the certified,
licensed, or registered professional, if any, who signed the plans and the building owner:
**I hereby request duplicate copies of the building plans on file with the Butte County Department of
Development Services, Building Division for: 3,Z J
Assessor's Parcel Number:
Located at:
(Address)
(City)
Permit Number(
(Zip Code)
I am aware of the following three provisions of the California Health and Safety Code as follows:
That the copy of the plans shall only be used for the maintenance, operation, and use of
the building.
That the drawings are instruments of professional service and are incomplete without the
interpretation of the certified, licensed or registered professional of record.
That subdivision (a) of Section 5536.25 of the Business and Professions Code states that a
licensed architect who signs plans, specifications, reports, or documents shall not be
responsible for damage caused by subsequent changes to, or use of, those plans,
specifications, reports, or documents where the subsequent changes or uses, including
changes or uses made by state or local government agencies, are not authorized or
approved in writing by the licensed architect who originally signed the plans,
specifications, reports, or documents, provided that the written authorization or approval
was not unreasonably withheld by the architect and the architectural service rendered by
the architect who signed and stamped the plans, specifications, reports, or documents was
not also a proximate cause of the damage.
Current Building Owner:
Signature of person requesting copies:
Printed name of person requesting copies:
Date:
Address:
Design Profession of Record:
Contact Phone Number:
Reason for requesting duplicate set of plans:
❑ Owner Permission- Date Sent: _
❑ Professional Permission- Date Sent:
FOR BUILDING DIVISION USE ONLY
Date Received
Date Received
K:ANI- W[BSI'l &1ildinv\Bui1ding Forms K Documents\Apprmed 2011 forms -handouts and on IistlARidavit Requestine
Duplicate Plans DBP -U7 IU.5.I I.doc-
Page 1 of 2
=OK
e.
"0=.Not''pplicable
= Not Ready MOBILE'HOMES MISCELLANEOUS ;: {..• .
Date - "`
MOBILE'HOME UTILITIES(Plans):OK.ezcept#'s ;"-'
;'Date
DECKS,COVERS,CARPORTS,GARAGES,.(Plans)OKexcepeWs
'
1. Zoning'Requirements-Setbacks-Easements
t'
-1. Zoning-Requirements-Setbacks_Easements -
:
. :2..S6IW'-Special MH;Support-Sketch :.
, : " ::
, • 2. Footings; Soils -Size -Depth -Spacing -Connectors -Steel.
- 3.- Sewer; Location-Test=Fall-C/,O,-Conciete;
Decks;' Girders and/or Joists -Deckingr.Bracing-Stairs-Rails
... .
,4. Water;,Location-Test- Ease ment, Needed (Sketch) .
:,
-4. Wood Awn:;. •Posts;Beams-Rftrs.-Connec.- .
Shthg., Rfg.-Bracing
Electricity; Location-Clearances-Grnd.-/ ;; /-Amp-Concrete
6. Gas; Location-Test-Wrap:•/,'.-•/'L"ft., ".
_. - /. ; -'/"Nat: or/--' /"L ftd/ - ,/"LP.G ; '
-5. Aium.'Awn.; Columns -Connections -Splice -Decal -Enclosures
�
'6. Carports; Windows -Doors
7. Utility,clearah6e
7.-El6c. _ r
_21
8. Frmg; Sills-Anchors-Studs.Rftrs,Trusses,..
9. Siding; Nailing -Veneer -Stucco -Mesh
4 ,
Card -131
-Date Card 61� ,:,: ;, Date ;.:
10. Roof; Shthg-Roofing
Card=131>
-..'.."'Date.;- :.t;'; Card -B1 •. i . 'Date,11.
Ext.; Steps boo'
Date
MO.BILEHOME INSTALLATION (P,.lans)`OK.except#'s'
1'. Zoning Requirements -Setbacks- Ease men ts;.•
Card -61
Date Card -131 Date
' 2. Footings; Size-Spacing-Marriage;Line :' .
: Card -131.
Date) Card -B1 Date
3.'Gas; MH Test -Demand -Valve -Connector,
`
4:' Electricity; MH Test -Crossovers -Breakers -Clearances:
iDate
POOLS (Plans) OK except #'s v
5. Drain; MH Test -Fall -Flex Connector;, a
1. Setbacks; Ease ments
6. Water,•MH Test -Regulator -Connector r2.
Soils; Compaction -Structure Stability
_7._Water and, Sewer Connected -C/O to.G,rade,HD-Approval
3. Pool Structure; Steel -Connections -Thickness-. .
Dead Men -Lining
8. Gas and .Electricity.Tagged" ti
9! Exits;,[ nsp.-Sketch .: <.
4. Elec.; Receptacles and Lighting; Distances -GH
_
10..Cert. of Occupancy , .
5. Elec.; Pool Lighting;,15.volts-GFI .'
>
6. Elec.; Enclosures;'Conduit Entries -Terminals -Listed
7. Elec.; Bonding; Metal w/5' -Circulating Equip: -Heater
8. Elec.;Ground ing; Equip. w/5' -circulating Equip. -Pool Lghtg.
Boxes-Enclosures-Panelboards-Ins. to Main in Conduit
Card -B1 Date Card
_ " `;, Card -61 Date -
Card -81'
_
"Date-, Card -B1 Date
9. Health Department Approval
+s �: v
��
10: Plumb.;: Cir. Test=Water Supply Test" .
Card -B1
Date Card -81 Date -
"Card -B1
Date i Card- B1- Date
= OK
0 = Not OK
Not Applicable
= Nat Ready
RESIDENTIAL (.Single and Duplex)':;
'_Date:
1W FLOOR; Plan's , OK exce t:#'s-':'
Date
FRAMING Continued `
flyrZ5g .0q
angers -Post Caps -Anchors -Connectors'.
t sin;=Solls'nSteel=Ela : rn .-/ /"`Ftg. Depth
Cing. Joist-Rftr. Ties=Purlin -Truss-Shthng.-Rfng.
fg:, Garage`; Soils -,Steel-/, `' /"'Ftg. Deptheplace-Ties
or -Type A Flue -Fireplace Throat
4. F ., orches & Decks; Soils -Steel=/ /"Ftg. Depth
; _
91tic Access; Size & Romex Protection -Draft Stop-lns..Bafflea
to s -Main; Steel-Blockouts-Wrapped
ArBgrm. Windows or Exiting Doors -Sill Hgt. & Dirriensions
t walls, Garage; Steel-Blockouts-Wrapped
ar ge Fire Protection Framing
lab• Wrapped
roperty LineFirewall& Openings
rs-k"rptam MY.7titeel
xt. Doors -One T -Check Garage -3rd story, 2 -exits
D.W.V.; ;Fall -Fittings -Test -2 way C/O -Sewer Test
emirs; Width -Headroom -Rise -Run -Landing -Fire Protection
10. Gas Pipe; Size-Anchorsb3-,Plywood
on Roof Overhang -Attic. Vents-Rafter.Outriggers
11. Water Pipe; Test -Anchors -Regulator -Service Test
4. Si ing-Nailing Veneer
12. Electric; UndergroundScreed-Fd...Vents-Underflr:,Acces8
13. Plenums & Ducts; Clearance-Material=Supprt-Ins.
._-56.=(fazing
Area -Glass. Protection -Skylights -Plastic':,
14. Girders -Sills -Anchor Bolts-Joists-Vents-Cripples
—P-Shegr:Walls; Nailing -Bolts;
15. Insulation L
58. Insulation-Wails=Clgi
.59. Infiltration-Walls-Wridws
Card -131
Date Card -81 Date
, :+ .
Card -B1
Date and -B1 Date
Card -B1
/�� Date't- 3 Card -Bt Date
;Card -B1
Date Card -B1-, Date
Date
LUING Permit OK except #'s
Water Ht. Vent -Access -Combustion Air
Date'
I Plans OK except #'s ,
, xt: Steps -Door & Sidelight Protection -Landings '
ater Pi e; st,& Anchors -Nail Protection
D.W.V.,. Fttngs &;Anchors -Nail Protection
- oke Detector .
Shower an; Test, First Floor -Tub Access
&VFurnace; Vents -Clearance -Comb. Air -Connector-
I arage; Above Floor-Ducts-Mech. Protection '
e Tub=&Shower, 2nd Floor -Tub Access
as Pipe; Size &.Anchors
B�dtoom:Exiting
. G.F.I. & Bath Fixtures& Tub Access -Spa
."
lac>:Tri 8 Subpanel; Breaker,:Sizes-Labels
Card -B1
Datel-% .,;Card -B1 !
Date
rs &Rails
Card -131
bate . Card -81 Date.&
-'Fireplace or Stove; Clearances -Hearth
Date
E ECTRICAL Permit OK except #'s
W.T48c. Outlets it Wood Panel; Int. & Ext.
Jz re:& Transformer Clearance -Ins. Protection
bY%jl. Fixt. & Appliance; Grnd. -Air Gap -Cooking Clearance
. I , . Receptacles Spacirig-Lights & Switches at Doors
. EI c. Outlets &.Receptacles at"Kit. Counter"'
Size Boxes & No. of Conductors -Stapled
.tietarage Fire Door; Swing -Landing -Closer
omex Installed Close to Edge of Studs & C
.C. Duct in Garage -Damper.
2 uip: Ground made up w/Mach. Fasteners and Gas &Water
I-�-�
tr. Htr.; Vents -Clearance= m . Air- onnector-P.R,V:
I Garage; Above Floor- Mecction
4?' --2 -Appliance Circuits in Kitchen & Conductor Size
fib., Elec. & Mach. Equip. Listed forLocation
u feed Wire Size / . / ga. Cukor AI-A.C. Wire Size / /ga.
Cu or -AI
fle . Receptacles in Garage; (G.F.I.)-Romex,Protec..
-2&.- tffige'Circ. / / ga. Cu or Al -Oven Circ. / / ga. Cu or Al.
Insul ted Neutral Yes a No
nsulation-Foam-Looked in Attic 13 Yes
77. Guard Rails & Deck. Construction -Post Caps
rvice=Riser, Conductors Gr al'n Disconnect
-7&.-"n. Vents & Crawl ,Hole Door -Drainage & Wood -Earth
Clearance Looked under Floor .. O Yes
quip..Clearances Panels-Motors-Mech. Equip.
62YClothes Closet Light -Shower Light -Spa Light
79. Following instld.;.Dri es. ❑ No; Walks es; p No;
Planters ❑ Yes -. ❑
80. S ucco; Br -F /1
Card -B1
Date 1 Card -131 Date
. A.. Unit; Disconnept, VfecWical, Plumbing
Card -B1
Date L Card -131 Date:
WVents Above Roof; Pibg.-Appliance-Firepl.-Clearance.to
Openings.
Date
MEC ANICAL Permit OK except #'s
�2'Wpter Well; Disconnect, Electrical, Plumbing
Ducts Insulation & Support
ant Fan; Exhaust above insulation
. x or Elec. Trim; G.F.I. Receptacle -Underground
ntilation throughout House
. ondensate Drain & Overflow; Size & Grade.
F rnace-Vent; Access -Comb. Air -Return Air Vent -115 outlet
Glas Protection
:.
o actions from Previous InpeCtions
'88-4fis Test -Meters Tagged; Gas -Electric
8AYfiter & Sewer Connected -C/O to Grade -HD Approval
Attic "ss ss & Pla rm if Furnace in Attic
Energy Compliance Certificate -Other Certificates
K. Energy
Date t '� Card -B1 Date I'
Card -131 is Date ;' . ;\4 Card -131 Date
Card -131
Date)K-7/Card-B1 Date
Date' `
FR&MING.(Plans) OK'except #'s
Card -131
Date Card -B1 Date
. Sills, Proper Material & Anchors ; '�
Card -131
Date Card -B1 Date
alls Studs -Nailing, Spacing & Bracing ',',Plates -Sound
confflepts at al:
40 -Searing Walls over Girders & Floor Nailirig
raf op in Walls jtat oof) f
e Stops; F Stairs -Chases -Tub
49rWeader & Beam -Size & Bearing..
(NOTE: An entry.must be made each time you visit job site)
COUNTY. OF .BUTTE
f DEPARTMENT OF PUBLIC WORKS
196 Memorial Way, Chico — Phone: 891-2751 -
7 County Center Drive, Orovi Ile — Phone: 538-7541
747 Elliott Road, Paradise — Phone: 872-6307
C®RRE TION NOTICE
OWNER PERMIT NO.
A routine Inspection Indicates that the following violations of County Ordinance
exist at the above address and should be. corrected,. Please notify this office
when correction of work Is completed. if you have any question pertaining to this
matter, or need. additional exp Ianation,..please contact.thiss office, Immediately.
Inspector
fI •. 1
. h
f COUNTY OF BUTTE
DEPARTMENT OF PUBLIC'WORKS
.'� 196 Memorial Way, Chico — Phone: 891-2751
7 County Center, Drive, OroviIle — Phone: 538-7541
747 Elliott Road, Paradise— Phone: 872-6307
CORRECTION NOTICE
OWNER PERMIT N.O.,
A routine, inspection indicates that the following violations of County Ordinance
exist at the above address and should be corrected.- Please notify this office
when correction of work is completed. If.you have anytquestion pertaining to this
atter, or eed additional explanation, lease contact this office Immediately.
v q
AMf
v.
MIFERMANAU
Inspector .Date
COUNTY OF BUTTE
f DEPARTMENT'OF.PUBLIC WORKS
196 Memorial Way, Chico— Phone: 891-2751
.7 County Center -Drive, Orov.i Ile — Phone: 538-7541
747 Elliott Road, Paradise— Phone: 872-6307
CORRECTION NOTICE
OWNER PERMIT NO.
A routine Inspection indicates that the following violations of County Ordinance
exist at the above address and- should be corrected. Please notify this office
when "correction of work is completed. If you have any question pertaining to this
matter, or need additional explanation, please contact this:office Immediately.:
Inspector Date
Owner. .Y Permit No, `
qW
j,
ENE.R.GY C,.ERTIF I'CA'T I0N
,
a
LOT #10.- Brandonburry Ct..Chico^
LOCATION' A.P. No. �r
DESCRIPTION OF INSULATION '.
_
ROOF .
'
Material __ Brand.Name
Thickness (inches) r Thermal Resistance (R Value)
.:
EXTERIOR WALL
- Material Fiberglass Brand Name-Certainteed
Thickness (inches). 31" Thermal Resistance(R Value) R-13
�".
CEILING'
`
Batt or Blanket .Type_ Batts` Brand Name CPrtain d
Thickness(inches) 10" Thermal.Resistance(R Value) R-30..
x
Loose,Fill Type Insul Safe III Brand.Name Certainteed
Minimum Thicknes�(Inches) 11 Number of Bags. Wt.,per bag lb:.
Area •covered(ft:`).. Thermal 94f tance(R va Ut: x~30
FLOOR, ELEVATED
Al
Material Brand Name
- Thickness(inches) :`Thermal Resistance(R Value)
t
FLOOR, SLAB{
Material .Brand Name
Thicknes_s(incEies) Thermal.Resistance(R Value)
Width (inciies,)'
,
-�
FOUNDATION'WALL. "
Material Brand .Name
t
j
:Thickness(inches) Thermal Resfstance(R'Value)
I hereby certify that the above insula t;Lon•.was installed in the above building.
}'
in. confoimance with .the State of.Califdrnia Energy Requirements. ;
SHASTA INSULATION. 272941
FIRM NAZU OWN -ER STATE CONTRACTOR'S LICENSE NO.
La d
'SIGNATURE OF INSTALLATION APPLICATOR - DATET
.S " • I , Nr4 F' Wit. .F T F v '. 4.Y4:{.y' i PR".% SFa[�
I' -hereby .certify the above;;insulation ardd all required items as shown on theme
have installed
Building Department approvedplans and., attachments been as-
required by" the State of California Energy .Requirements.
All equipment, devices and materials are. of the quality prescribed or.are µ "
specifically approved by the State of California.
FIRM /OWNS (Please print) STATE CONTRACTOR'S LICENSE NO..
G RE OF'GENERAL CONTRACTOR OWNiER DATE
C� THIS CERTIFICATE MUST BE ON,FILE WITH THE BUILDING ;DEPARTMENT PRIOR TO FINAL
INSPECTION APPROVAL AND A COPY SHALL BE POSTED WITHIN THE BUILDING.
1. January 1984 F
Gr�
e. COUNTY -OF BUTTE - DEPARTMENT OF.PUBLIC WORKS IT NO.:`
7 County enter:bri
_C ve:-.Oroville, i rnia,95965 - Telephone: 916/538-7541
' Calfo
APPLICATION ANGIPERMIT'
AS SS9 R &A C,�5,NUM.Y'R
ZONING
BUILDING PERMIT
'O'WNER
.77Z5V C. y��A)
-TELEPHONE
FT.,� OCC. 'BUILDING VALUAJION
.S MA
-0 A LING AD
COOTRAC11— S ITELEPHONE.,
CONTRACTOR 'S'MAI LI�ADDRESS
4.
JFireplace__
CONSTRUCTION LENDER.
NKNOWN$
Total Valuation
Filing Fee
$ 10.00
LENDER'S MAILING'ADDRESS
Permit Fee
$
ARCHITECT OR --ENGINEER -
LICENSE NO.
Plan Checking Fee
$
Energy Plan Checking Fee
$
ARcHI-TECT.OR ENGINEER!S MAILING'ADDRESS
Penalty
BUILDINrt, ADDRESS
-Permit.fee.
,PLUMBING PERMIT.
Filing Fee 10.00
Each Trap
2.00
Solar,or heat pump. water.heater
20.60
LOT NO.
SUBDIVI�..N NAME
PARCEL MAP,
C,
-Water piping
5.00
Eachlqa's Water heater or vent
5.00
USE OF.:STRUCTURE
SF bup!exF�" Mobi I 'home El Other
I P , . . . I0-00
SPECIFY
-Gas piping system.1 5 outlets.
5.00 azt.
Building sewer
5.00
Mobile Home S W -
1 5 eq:
TYPE OF WORK
New AdditidnEl '541,'1e:mq_dt1 0 Uti lities 'Installation Other ❑
Describe work: '62�v
JA 4 flC2v
L!IA-51 PC J V,
Permit Fee
Contractor
ELECTRICAL PERMIT FilingFee 10.00
service 800V OR LESS
Main'AJS
100 AMP OR LESS - �10.00
.
Main service EA. ADD -L 100 AMP
2.50
CONTRACTORS LICENSE LAW- .
.1 de /.n e
c under penalty of perjury (c�hebk.one):'
I amlicensed under provisions of Chapt. 9,.Div. .3 of the Business,W
1 ,
and. Professj�q Codend my license Js -in f force and effect.
Li.cense No. Classif !cation
0 1, as the owner,Or my employees with wages as their_ sole compen:'
safion, -will do tbe.work,and the structure is not intended or offered
for sale. (Sec. 7044)
.-F] I, as the owner, am exclusively contract,ing- with l,icensed contract-
ors. (Sec. 7044)
❑ I aryi exempt under Sec' B bsiness and. Profession s,Code
for this reason
NEW CONST. ( DWELLING.00CUP..) 21/2 Osq ft
OR A.CNS. ACC; BLDGS.
NEW CONSTR . MULTI -OUTLET 7-
NON-RESID, BRANCH CIRCUITS ) 2.50 ea
POWER APPARATUS &).
(.SINGLE OUTLET CIR
20@50t
Ex.*O ccup( 0.U*TLETS OR,..FIXTURES .13ALO 301
1. FIXED APPLNS, OR
Ex.'OccUP-. QUTLETS (RE SID E J 2.00
Temporary -.service .10.00/41 -9:510
Mobile Home Facilities 15..00
Misc..iWiring 15.00
Perml IF ee $ z
Contractor
WORKMEN'S COMPENSATION INSURANCE
I declare under enalty.of -perjury (check one):
Tbepermit.is-for,$100.00 (valuation).or less.
have, placed, on file with the County of Butte Building- Department
Certificate of Workmen's Compen"sation-Insurance or. a Certificate
of -Consent to Self -Insure.
I shall: not employ any person in any manner, -so as to become subject
-th W. -C., laws of'dal'ifornia.
t 0 e�l
Notice to Applicant: If I after making tois•stateriieht, should you bec6me subject
'to the W. C'.provisions of the;LaborCode; you •must forthwith comply with such
provisions or this permit shall be deemed revoked.,
MECHANICAL PERMIT
Filing Fee .10.00
--Heating 2_ !:!;rA,'
Cooling
Ho6d
3,.00
Venti lation.
-3
Permit Fee
6W
Contractor
z
I certify' tharl� have7 read this: application and state that the above information.
is -correct. I,adree-,to, comply to all County Ordinances and State Law-, relating
to building co t ucVn, and,hereby authorize representatives of the Cou-n . ty ot
Butte to enter' u c n above-m6ntioned property for inspection purposes.
gainst
I also agree s e,in deyflify. and keep harm I ess.the. County.of Ate5
all,liabditi . , r RVcost%, and y in Ywal accrue
againstS. nt in Oence of the granting of this, t.
nat
S i 7t. 7r. f '
gfn.Applicant wne
An OSHA permit 'islrequireld for. exccivationso'ver 5'0,"'deep and demolition a r construct-,
ion of structures over'3 stories:in:height.
Mobile Home Installation Fee
Energy. Inspection Fee
TOTAL "PERMIT FEE/ $
eUP.
J CONST.
V
S�o
11
,
[fJPAJ
L
'_:Df I
_1�_
This permit is hereby issued under
lslon's-of the Butte County Code and/or
work indicated above for which
DIRECTO D OF PUBLIC
-B
B
P E IT -E , X I PIR . ES --bate--
the applicable prbvi-
resolutions to-do
fees. hive" been paid.
WORKS
Date /2 11-ely 7
v —;P>
N
Receipt-. o.—L
P.W...YELLOW-,A5SE350R. PINK-INSPE
WHIT[-D.CTOR. COCDENROD-APPLICANT
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COUNTY OF BUTTE - DEPARTMENT ,OF PUBLIC WORKS - BUILDING DIVISION
7 COUNTY CENTER DRIVE-.OROVILLE,CALIFORNIA 95965 - TELEPHONE: 916/538-7541
PERMIT APPLICA- DATA. SHEET
OWNER
Proposed Building Use
Permit No./ ,✓
A. P. No.rGw ' 17-%�7
Building Inspector,�� Date
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 sLgned by p'epi6rer hof plans. P
3. Complete plans in duplicate/triplicate, signed by preparer of plans l• 4. Complete Complete engineered plans and calcs, with wet signature on plans.
5. Plans with Energy Design Compliance Statement.
6. School District "Fees Paid" Stamp on Floor Plan.
7 Statement of Intent for Non -Heated and AC Buildings.
8. Fees of $ . . . ... . . .
eter of signature authori ion. . . . . . .
Sd anitation approval from _ HeaVth Dgpt, t
11.' Planning approval for (A) Use:�arking:A 0,
12. Certificate of Workmen's Compensation Insurance. . . . . . eKt
13. Contractor's License Information (no., name style, classif.)
_14. Owner -Builder Verification (Given to owner❑, Mail to owner ❑ )
:r
15. Improvements may be required. . . . . . . . . . . .
16. Mobilehome Installation Data. . . . . . . .
Pre-Inspec. request to (Date)
17. Pre -Inspection for ._____ -_ _ Required- Building Inspector
18. Recorded copy of Agricultural Acknowledgment Statement.
19. Driveway Permit-
_ 20. Plot plan approval from city of -
21.
f_21.
22,
When you issue the permit, process as follows: Mail owner; ��aii to contractor.
Telephone and hold for pickup / office, Deriver w/inspedtor.
Other
AppIic Date
Copy of plans sent Health Dept.; File Dept., Other Date
The following data must be submitted prior t permit issuance' (Circle new item not checked above).
1. Index permit for above items No.
2. Additional items required: _ --_
Plans checked
Copy -DPW
Date Plans approved by
Sets of plans on hold in File cabinet AP folder
Date I v -
ontract , designer, owner, was advised of above required data by_phone_Jnail—counter
by
date �� " (Z Y7
Contractor, designer, owner, was advised cl above required data by
—phone —ma iI—counter
4—
date
Plans checked
Copy -DPW
Date Plans approved by
Sets of plans on hold in File cabinet AP folder
Date I v -
o
fir,
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a.
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RE: Dtfugwgi;'Clearance
T
a
5fe�eJe
a 6�z
- -13-- p
owner
.,-
location -;
AP . -..
Driveway ;permit` .,8-7�2 7Z
has been` issued for the above
property.
q num
l
s IgnavGr&
date
RESIDENTIAL PLAN CHECKING GUIDE 7/85
(S.F., DUPLEX & MISC. ONLY)1�JTEIZ 17Z'g Z
Bldg._ Permit, # 3 - 3-3
OWNER 4N E_ A. P. /l 2 .- - o :7 FALT
GE��Ing.lrequirements:
ERAL
1�! f(sideyards and number of permitted living units).
2�✓�aluation.
3Pans signed by designer.
4.4 -'Energy Design and Compliance. .
xis ing .violations on property.
PLOT PLAN
1 Y complete parcel size and dimensions.
2. etbacks, sideyards, easements, etc.
3Other buildings or structures.
ra ing, fills, drainage.
5Y Flood hazard.
Er ---'Special conditions on creation map or compliance document.
FLOOR PLAN
1 �omplete to scale plan with dimensions.
2. equired windows for light and ventilation (Sec. 1205).
.3.v equired windows for second exit (Sec, 1204).
4.V,Skylights (Chapter 34 & Sec;. 5207)
5.iman impact glass (Sec. 5406).
6.Y✓Re'quired room sizes, ceiling heights (Sec. 1207).
7.✓G.F.C.I.'s in baths, garage and exterior outlets (Article 210-8).
8.ght fixtures, switches, receptacles, and exterior receptacles for maintenance of
,-eechanical equipment..
9. Locations of water heater, heating and cooling equipment, other electrical or gas
,equipment, and plumbing fixtures. S
10 V. /Garage firewall, door size, and closer (Sec. 503(d)(3)).
11-1 - 3'0" exterior exit door (Sec. 3304(e)).
12. �F'ireplace and wood stove location.
13. Smoke detectors (Sec. 1210).
STRUCTURAL DETAILS
1..✓ Foundation plan complete enough:.:to construct building.
2-.---F'V r construction details complete enough:to construct building.
3.✓ levations and wall construction details complete enough to construct building.
4.Y Roof construction details complete enough to construct building.
5 7FMplace construction details and calcs if necessary-.
6.1"Sufficient data and details to satisfy energy requirements (State Law) (Form 1).
MISCELLANEOUS ITEMS TO LOOK OUT FOR
,..L.---Frx?osure I plywood on exposed locations and overhangs.
2--Ste-i-rway details: landings, rise and run, head clearance, handrails -(Sec. 3306).
3__—Guar&ra t -details. (Sec. 1711 & 3306(j))..
or stone -veneer (Chapter 30) ..
51l terior plaster -.,weep screeds (Sec. 4706').
6 oper roof -pitch for roof covering (Chapter" 32)
7 Rafter ties or bearing ridge "beam.,
RESIDENTIAL PLAN CHECKING GUIDE (CONT'D) 7/85
MISCELLANEOUS ITEMS -TO LOOK OUT FOR (CONT'D)
8 Garage -door or porch header sizes.
9k-"'A� dequate bracing.
over garage - complete 1 -hour separation required on garage side
including supporting walls and posts, etc.
11:-- oT o i s on three-story dwellings (Sec. 3303 & see Mezannines 1716).
12. Attic access and ventilation (Sec. 3205).
1.3 VTf-lvor access and ventilation (Sec. 2516).
14.�T�iod stoves, clearances, alcoves & 1 -hour shafts.
15. Combustion air for fuel burning appliances.
+6. ---Noise oise requirements on duplexes.
1 oils - special foundation design.
Lov--4&aining walls requiring design.
19 --Ungual shape, size or split level house requiring lateral design.
, •1
BUTTE COUNTY
DEPARTMENT. OF DEVELOPMENT- SERVICES` ; : s
.. BUILDING PERMIT:
24 HOUR INSPECTION (IVR): (530) 538-4365
Y
"OFFICE. (530) 538-7541. FAX#: (530)1538-2140
ONLINE PERMIT/RENEWAL PAYMENTS, www.buttecounty.net\dds
_
BRANDONBURY�LN , Owner: I Permit NO: -
Site Address: 835'
B08-:1209
APN: 042=630-013 '
HANNEMANN, PATRICE
Issued Date: 06/24/2008 By 'TMP
Permit type: MISCELLANEOUS;
835 BRANDONBURY' LN '
Subtype:: Re -Roof
`; CHICO; CA 95926 1
'Expiration Date:, 06/24/2009 x
Description:. , REROOF 37 SQ'S SHAKE TO;COMI
Occupancy: Zoning` ASR ('
Contractor
Applicant-, ' 'r:. . I,
Square.Footage ',....
BOE ROOFING
BOE ROOFING r
-Building .Garage •, RemdUAddn
3126 JOHNNY LANE
:. 3126 JOHNNY -LANE-,
-
CHICO, CA .95973
CHICO, CA 95973 -
Other Porch/Patio • Total
(530) 34224919,
(530)342-4919.
i
F
FEE INFORMATION k g
DBMSC Re -Roofing $233.00
-7otal'Charged: $233.00^ Fees Paid: $233.00
Balance Due: $0.00 ' Recei tNo: ` B7789.'
LICE_NSED C_ONTRAC_ TiOR'S_DE_CL_A_RATION_^'
OWNER`%BUILrD_ER DECL_A_RA_TION'
}
Contractor Name State Contractors License No / Class / Expires •
] P
I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am exempt from the Contractor's License
BOE ROOFING.. " 820046,/ C39 '/'05/31/2000
Law for the following reason (Sec. 7031.5), Business and Professions Code: Any city or county that
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
I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am licensed under.jirovisions of Chepter.9
(commencing with Section 70 00) of Divisiori3 of the Business and Professions Cone, and my license
pursuant to the provisions'ofithe Contractors Law_[Chapter 9.(commencing with Section 7000)
is in full force and effect.-
of Division 3 of the Business; and Professions Code] or that he or she is exempt therefrom and the
yy
A-� ` O6/24/2OOS
"� /l -
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
Please check one of the following:'
C6ntract6 s Signature Date
_ _ _ _ _
'
I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE
WORKERS' COMPENSATION DECLARATION
COMPENSATION, WILL DO THE WORK AND THE STRUCTURE ISNOT INTENDED OR
OFFERED FOR SALEL(Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of the property, who builds or improves thereon, and who does
the work himself or herself or-through'His or her own employees, provided'thet such improvements
I HEREBY AFFIRM UNDER PENALTY OF PERJURY one of the following declarations
❑I HAVE AND WILL MAINTAIN A CERTIFICATE•OF.CONSENT TO SELF -INSURE. FOR `',; •.
-Section
are.not intended or offered for sale. If, however,.the building or improvement is sold within one
WORKERS' COMPENSATION,- as provided for by 3700 of the Labor Code: for the, . -
year of oompletion,'the owner -builder will have the burden of proof that he'or she did not build or ,
performance of the work for which this permit is issued..
improve for,the purpose'of sale.):
❑I HAVE AND WILL MAINTAIN WORKER'S' COMPENSATION INSURANCE; as`regwred by,
EJ 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED •
CONTRACTORSTO CONSTRUCT THE PROJECT (Sec. 7044, Business and Professions Code:,
Section 3700 of the Labor Code, for the performance of:the work for which.this;permit is issued.
The Contractofs License taw doves not apply to an owner of the props who builds or improves
-My-Workers' Compansation msurenie carr er and policy number are,
`thereon, and who c6mracts.for the projects with a contractor(s) license pursuant to the
Camer.'STATE FUND .. Rolicy.Number713-0017668 - EpDate:08/01/2007
Contractor's License Law.).
'
^'
_ (This sedron nee not competed if the permit ,s or on—e hun r, dTollars ($100) or..ess.
a' ';
" [''' •" �
❑ IAM EXEMPT under Section B. 8 P.C. for this reason:
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
m
'ISSUED, I shall. not employ any person in any manner.so as to become subject -to the Workers'
'
- -
O6/24/2OOS
. Compensation Laws. of California, and agree that if I stiouldbecome subject to theworkers' .
X
compensation provisions of Section 3700 of the Labor Code I shall forthwith comply with those
Owners Signature J' Date
provision�S.- , t
X
06/24/2008
I hereby certify that have read this application and state that the above information is correct. I agree
to comply with all City and County ordinances; rules, regulations, and State laws relating to building `
,Signature Date
construction, and with any and all conditions of permit. I agree to defend, indemnify; and hold harmless
WARNING: FAILURETO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL_
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIESAND CML FINES UP TO ONE
Butte Coun ty, its offcors,lagents and employees from any and aIl,Gaims and liability for personal
HUNDRED THOUSAND DOLLARS ($100,000); tN ADDITION TO THE COST OF COMPENSATION,
njury, including death, and property damage caused by, arising out of, orin, any way connected with
the issuance of this permit. I hereby acknowledge that issuance of this permit does not authorize the
DAMAGES AS PROVIDED FOR INSECTION 3706 OF. THE LABOR CODE, INTEREST AND*
use or occupancy, of any sidewalk, street, or subsidewalk. I hereby authorize representatives of Butte .
ATTORNEY'S FEES.
County to enter. the above mentioned property for inspection purposes. I hereby certify that I em the '
props er thorzed to act on the property ownersbehalf.
.
'a-�--�; 06/24/2008
°CONSTRUCTION <LEN�DINGAGENCY a ; , ;
. �._ _ .
I HEREBY AFFIRM UNDER PENALTY'OF PERJURY that there is a construction lending agency for
Name of Permittee [SIGN] Print ' Date
the performance of the work for which this permitis issued. (3097 riv. code)
Owner ' ,contractor OR; . E]Ag ' t forOwner Agent for Contractor
FILE COPY 1'
Lender's Address City.. State zip .
BUTTE COUNTY
0 o DEPARTMENT. OF DEVELO.PMENT-SERVIS
i T.*C
BUILDING PERMITAPPLICATION
o c
OFFICE #: (530) 538-7541.•, FAX #• (530),53 8-2140
c ` A FEE WILL BE REQUIRED,AT TIME OFAPPLICATION
C y website: www.buttecounty net/ id '
OV N� PLEASE.PRINT�CLEARLY
"When filed, this application and all supporting material becomes subject,,to the CaliforniatPublic Records,Act All public information,
related to this application is subject'to public inspectionland will be posted on the County's website for electronic access.
OWNER INFORMATION'
Last Name
Ski -)K s .
First Name
dui
Mailing Address $35�: a,Qi�►�DowY.
City I C b
State C° 14 . : '
Zip qS9
Phone 3 y t?�. '
Fax ,
E-mail
CONTRACTOR
Name
Name
Address .,� G . �o hl wN Y,
N.
City C ill C[�'
State
sp_,?, 973 .
Phone3 `/Z -4 9 9
Fax .
E-mail
Ix.#vZ'oo Y4
Class G -3'9
APPLICANT INFORMATION
Name
Address
City. State zip,
Phone Fax
APPLICANT SIGNATURE.
!' }+PROJECT LOCATION
AN Z 1
Property Address,
City
i
WORKER'S COMPENSATION
Policy Number
,71.3:4.7�.c�:.'
Carrier S 7.�j TLr FaAL11D
If hiring anyone other than licensed contractors, a cerdflcate of
worker's compensation. must 6a shown at the time of permit issuance:
f' LENDING AGENCY .
Name �' • '
Address Y"
DESCRIPTION OR SCOPE OF WORK:
�r ve o4F 3 7'c7
i
I.
Sq FT- Living, Garage - " _ Open Cov
'D Structure Built without Permits
D Proposed Change of Occupancy
(Note revious use)•
For office use,onl
ARCHITECTIENGINEER .
Name
FloodZone'
Addres's
SRA.
City
No
State
Zip.
Phone ..
Fax
E-mail'
State License Number.
APPLICANT INFORMATION
Name
Address
City. State zip,
Phone Fax
APPLICANT SIGNATURE.
!' }+PROJECT LOCATION
AN Z 1
Property Address,
City
i
WORKER'S COMPENSATION
Policy Number
,71.3:4.7�.c�:.'
Carrier S 7.�j TLr FaAL11D
If hiring anyone other than licensed contractors, a cerdflcate of
worker's compensation. must 6a shown at the time of permit issuance:
f' LENDING AGENCY .
Name �' • '
Address Y"
DESCRIPTION OR SCOPE OF WORK:
�r ve o4F 3 7'c7
i
I.
Sq FT- Living, Garage - " _ Open Cov
'D Structure Built without Permits
D Proposed Change of Occupancy
(Note revious use)•
For office use,onl
Zoning
! ` .
FloodZone'
SRA.
Yes
No
OX. j; =Type
Const.
PROJECT INF�ORMATION'�
Site Addi ass 835'BRANDONBURY LN
PeI1111t No. B07"0763,v}
APN. 042=630-013
HAI NEMANN, PATRICE MAE
Date: 04/10/2007 ;: By GLB
Permit type: ' MISCELLANEOUS '.
835 BRANDONBURY LN' .,Issued
Subtype: HVAC.Ctiaoge Out
CHICO; CA 95926
Expiration Date: 04/09/2008 "
Description .:HVAC CHANGE OUT i
r . {
'Occupancy: Zonmg:ASR ;-(..
Contractor'
:'Applicant:' '` _ !
Square Footage
TOM'SAIR'CONDITIONING
TOM'S' AIR CONDITIONING
Building'.' Garage RemdVAddri
-P O BOX, 6262
P O BOX 6262 I
CHICO;'CA 95927:-:
CHICO CA 95927 .
'
Other Porch/Patio- Total
(530).864-2406
(530) 864-2406
•' FEE INFORMATION
DBM.Heat.Pump (Package.Unit)..:
Total Charged: $55.00 Fees Paid: $55.00
Balance Due:. $0.00 '. Receipt No: B2596,
LICENSED CONTRACTORS DECLARATION ;`
_..
, _ ,' `IOWNER /,BUILDER DECLARATION+ .
Contractor (Name) State Contractors License N0. / Class / Expires
I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am exempt from the Contractor's License
TOMS AIR CONDITIONING C576836 / /
Law for the following reason (Sec. 7031.5), Business and Professions Code: Any city or county that
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
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
- pursuant to the provisions of the Contractor's License Law [Chapter 9 (commencing with Section 7000)
. is in full•,foMnd.-. �.`�'; -- - -
- of Division 3 of the Business and Professions Code].orthat he or she is exempt therefrom andthe -
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit's ubjects
X 04/10/2007
the applicant to a civil penalty of not more than five hundred dollars [$500];
Please check one of the following:
Contractor's Signature. Date. % i
D
I, AS OWNER OF THE PROPER
COMPENSATION, WILL DO THE WORK, AND THE STRUCTIURE IS NOT (INTENDED
WORKERS' COMPENSATION TION
_ DECLARA,
OR
_.OFFERED FOR SALE (Sec.17044, Business and Professions Code: The Contractors License
" "
I HEREBY'AFFIRM UNDER PENALTY -OF PERJURY one of the following declarations:' `
Law does not apply to an owner of the property; who builds or improves thereon, and who does .
the work himself or herself or through his or her own employees, provided that such improvements
cF]I HAVE AND WILL MAINTAIN A`CERTIFICATE OF.CONSENT TO SELF -INSURE FOR
are not intended or offered for sale. If, however, the building or improvement is sold within one
WORKERS' COMPENSATION, as provided for by Section 3700 of the Labor Code, for the
year of completion, the owner -builder will have the burden of proof that he or she did not build or
performance of the work for which this permit is issued.
improve for the purpose of sale.).
I, AS.OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED
E]I HAVE AND WILL MAINTAIN WORKER'S COMPENSATION INSURANCE, as'required by
CONTRACTORS TO; CONSTRUCT THE PROJECT (Sec. 7044, Business and Provessions Code:
Section 3700 of the Labor. Code, for the performance of the work.for which this Permit is issued,The
Contractors License Law dows not apply to an owner of the property who builds or improves.
My Workers' Compensation insurance carrier•and policy number are;
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to thee'.
F 'e
Contractors License Law.). }
Camey. - Policy Number. Exp. Date:
(This section neeU not be competed if the permit isfor one ur ollars($100) or ess.
1 AM EXEMPT under Section B. & P.C. for this reason:
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
SUED, 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'
X , 04/1 0/2007
compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those
Owners Signature • _.; Date . '•
provisions.,
X 04/10/2007,
1 hereby certify that I have read this application and state that the above information is correct. I agree
to comply with all City and County' ordinances; rules,regulations, and State laws relating to building .
signature Date
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
construction, and with any and all conditions of permit. I agree to defend, indemnify, and hold harmless
Butte County, its officers, agents and employees from any and all and liability for personal'i
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP. TO ONE
injury, inducting death, and property damage caused by, arising out of; or in any way connected with '
t of o
HUNDRED THOUSAND DOLLARS $100,000 , IN'ADDITION TO THE COST OF COMPENSATION,
( 1
the issuance of this permit. I hereby acknowledge. that issuance of this permit does not authorize the.
DAMAGES AS PROVIDED FOR INSECTION 3708 OF THE LABOR CODE, INTEREST AND
use or occupancy of any sidewalk, street, or subsdewalk. I hereby authorize representatives of Butte
ATTORNEYS FEES.
County to enter the above mentioned p party for inspection purposes. I hereby certify that I am the
Pro er or autkorized t on the property owners behalf. '.
CONSTRUCTION. LENDING AGENCY -.
_ _ , __..
.04/10/2007•
I HEREBY AFFIRM UNDERPENALTY,OF PERJURY that there is'a construction lending agency for
NaMe o Permittee [SIGN] i Pnnt• Date
the performance of the work for which this pernifis issued: (3097 civ. code)
4
Owner: Contractor A antfor'Owin
Gf2 9 Agent for Contractor;
t ,
COPY
Lender's Address City State ZiprFILE
.
�
BUTTE:COUNTY Y
0 0, DEPARTMENT O.F DEVELOPME:NT SERVI"CES_,
BVILDJNG TERIVIIT APPLICATION
OFFICE #: (5365'5j'9-154iFAX4(530),538-2I40"-'t'
-'" =� c A FEE WILL BE REQUIRED AT TIME OF.APPLICATION
o.. -
C y . Website ;www liuttecounty net/dds
�U.N**PLEASE PRINT CLEARLY* }
'OWN
ER'INFORMAT/ON
Last Name r t -N me -r,.3 k
r- �-t�
Mailing Address $� 1
s
City Stated Zip q b>
F. PROJECT'LOCAT/ON
PropertyAddress C.J
City
k V
'��I L 111411 11 N
r
„AFP..LI,CA'NT /GNATURE
r
('
„` � 6
For,office use on.
Zoning
Flood Zone . '
SRA
lyes
No
,
7,,',`
Occ
Type Const
6� w, SPre- .
BUTTE COUNTY AREA
DEPARTMENT OF DEVELOPMENT SERVICES 5
INSPECTION CARD MUST BE ON JOB SITE
24 Hour Inspection Line: (530) 538-7636 (Oroville) (530) 891-2834 (Chico)
Office: (530) 538-7541 Fax: (530) 538-2140 Website: www.buUecounty.net/dds
Permit No: B07-0763 Issued: 04/10/2007
Address: 835 BRANDONBURY LN Area: CHICO
Owner: HANNEMANN, PATRICIAPN: 042-630-013
Applicant: TOM'S AIR CONDITIONMap Page: 14 C. 3
Permit Type: HVAC Change Out
Description: HVAC CHANGE OUT
Flood Zone: None SRA Area: No
SETBACKS
Front Setback: Side Setback:
Rear Setback: Other Setback:
um Setback From Centerline of Street:
ALL PLAN REVISIONS MUST BE APPROVED BY THE COUNTY BEFORE PROCEEDING
Inspection Type
IVR INSP DATE
Setbacks
132
Foundations / Footings
111
Pier/Column Footings
122
Grade Beams
114
Eufer Ground
216
Forms/Stee l/Holdowns
122
Do Not Pour Concrete Until Above are Signed
Pre -Slab
124
Gas Test House
404
Gas Test Yard
404
Masonry Grout
120
Masonry Bond Beam
119
Underfloor Framing
149
Underfloor Ducts
319
Shear Transfer
136
Under Floor Plumbing
412
Under Slab Plumbing
411
Gas Piping
403
Do Not Install Floor Sheathing or Slab Until Above Signed
Holdowns/Straps
122
ShearwalVB. W.P.-Interior
135
Shearwall/B.W.P.-Exterior
135
Roof Nail/Drag Trusses
129
Do Not Install Siding/Stucco or Roofing Until Above Signed
Rough Framing
128
Rough Plumbing
406
Rough Mechanical
316
Rough Electrical
208
Gas Piping
403
Shower Pan/Tub Test
408
Fire Sprinkler Test
702
Fire Sprinkler Final
702
Building Final
802
Electrical Final
803
Mechanical Final
809
Plumbing Final
813
Pool Final
802
Mobile Home Final
802
Ins ection Type I
IVR I INSP DATE
Do Not Insulate Until Above Signed
Wall Insulation
117
Ceiling Insulation
118
Do Not Cover Until Above Signed
T -Bar Ceiling / RC
145
Stucco Lath
142
Stucco Scratch
143
Stucco Brown
144
Swimming Pools
Setbacks
132
Pool Plumbing Test
504
Gas Test
404
Pre-Gunute
506
Pool Elec/Bonding/Light Nitch
502
Pool Fencing/Alarms/Barriers
503
Pre -Plaster
507
Manufactured Homes
Setbacks
132
Blocking/Underpining
612
Tiedown/Foundation System
611
Site Utilities/Trench Insp.
137
Gas Test Yard
404
Manometer Test
605
Continuity Test
602
Skirting/Steps/Landings
610
Coach Info
Manufactures Name:
Date of Manufacture:
Model Name/Number:
Serial Numbers:
Length x Width:
Insignia:
yFinals
Public Works Fina
538-7681
Fire Department/CDF
538-7111
Env. Health Final
538-7281
Sewer District Final
**PROJECT FINAL
801 OL
-rrolect runai is a ♦.cruncatc ill "ccupaucy iur (ncawcuuai "lily/
PERMITS BECOME NULL AND VOID I YEAR FROM THE DATE OF ISSUANCE. IF WORK HAS COMMENCED, YOU MAY PAY FOR A 1 YEAR
RENEWAL 30 DAYS PRIOR TO EXPIRATION
Inspector Copy
1A
CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page 3 of 8) CF -4R
Project Address
Builder Name
Builder Contact Telephone
OYt� N (rf �• .� Q
Plan Number
,
HER Rgaer
c...� Telephone
Sample Group Number An
Compliance Method (Prescriptive) y yr
Climate Zone
Ce g 'gna a .Date
Sample Hesse Number
Firm &y-
E� Hr id r
Street Address:
- � O
Ci /t ate/Zip.
-ev 14
Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT ,
HERS RATER COWLIANCE STATEMENT
The house was: ✓Tested ✓ ❑ Approved, -as part of sample testing, but was not tested
*
As the HERS rater providnig.diagnostic testing arid�field verification, I certify that the house identified on this form complies with
the dia stic tested compliance requirements as checked,6ntthisform:
✓ J The installer has provided aropy o CF -6R (Installation Certificate)
sKI -� 3 IN
THERMOSTATIC EXPANSIONVALVE (TX _�
ProceduT es for field veri�cateon of the mostottc ezpansTon valties are avarlaµble in RACM;Appendix RI
Verification for Reauired Refrigerant
without Thermostatic Expansion Valves
Outdoor Unit Serial #�?
Location
Access is provided fo> inspection. The procedure shall consist of
"Ne�"
✓
O Yes
❑ No
visual uerifica66h,*it the TXV is installed on1,thersystem:a�id
❑
Date of Verification
A ,
installation of the}§ ecific equipment shaf b6' ,' r fieri: ',
(must be checked monthly)
,
,�
��� .��r,�s, ,ti..n� t ,:;.s, �;�.. �•_,�.,��F Yes,isa pass.
Pass
Fail
Verification for Reauired Refrigerant
without Thermostatic Expansion Valves
Outdoor Unit Serial #�?
Location
Outdoor Unit Make
"Ne�"
Outdoor Unit Model
Cooling Capacity
Btu/hr
Date of Verification
A ,
Date of Refrigerant Gauge Calibration
(must be checked monthly)
,
Date of Thermocouple Cahbrat�on
(must be checked monthly)"
t
Standard Char e'Measurement (outdoor`air dry-bulb' S5`°F and aboveZ 1' b
Note: The system should be installed and charged in accordance;; with the manufacturer's;specificat ons and installei.verification .
shall be documented on CF -6R before starting this procedure. If outdoor air dry --bulb is below 55 T rater shall use the Alternative
Charge Measure Procedure
Procedures for Determining Refrigerant Charge using the Standard Method are available yin RACM Appendix RD2.
✓
11 Yes ❑ No A copy of CF -6R (Installation Certificate) has been provided mith refrigerant charge
measurement documented.
CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Pagel of 8). CF -4R
Project Address
Duct Pressurization Test Re ults (CFM Q 25 Pa) _ � " '
Builder or Installer Name
�3s /�rgrs�iatilour
-
om iherri�
Builder or Installer Contact
Telephone
1' ermit (Additions or Alterations) Number
Enter Tested Leakage Flow in CFM:
/
.2 eloe.,
HER5,Rater
Tele
'Sample Group Number 45;0.,
�phone
Compliance Method (Prescriptive)
Climate Zone
Certi!8�
Date
Sample House Number
�ia
in x .,. t..
.
FirmProvide
HC.
J ✓' L r�
FF—rA s
Street Address: VCi
/State/Zip:
o I
I
1'eo. sss'- z
Uoptes to: BUILDER, HERS PROVIDER AND BUILDING DEPAK•1'MENT
HERS RATER COMPLIANCE STATEMENT
The house ,was: ✓ ETTested ✓ ❑ Approved aspart of sample testing, but was: not tested
-As the HERS rater providing diagnostic testing and i6ld�venficatton I certify that theihouse identified on this form complies with
the diagnostic tested compliance requirements as cti&ked7✓ on ttus�'0% The HERS rater must check and verify that the new
distribution system is fully ducted and correct tape is used4before a CF -4R may be released on every tested building. The HERS
rater must not release the CF -4R until a properly completed d signed CF 6R has been received for the sample and tested
buildings. FrT
l�The installer has providedka copyCF 6R (Installation Certificate) {
a ":. r £i
Cd'New ducts are fully ducted � e does not use building cavities aas plenums . platform returns in lieu of ducts).
New ducts with cloth bad ked, robber adhesive duct tapesnstalled%mashc and draw bands are used in combination with
cl th backed, rubber adhesive duct to a to seal Leaks at duct connections s = r
�,x.. PA )
✓ MINIMUM REQUIREMENTS FOR i)UCT'LEAKAGE REDUCTION COMPLIANCE CREDIT
Procedures for field verification and diagnostic testing of air distribution systems are available in RACM, Appendix RC4.3.
Duct Diagnostic Leakage Tesimg°Results w ' „
NEW CONSTRUCTION°s"
Duct Pressurization Test Re ults (CFM Q 25 Pa) _ � " '
Measured
Values .
1
Enter Tested Leakage Flow in CFM:
� Measured
Fan Flow: Calculated (Nominal ✓ - f }Doting ✓ OfHeatmg)or ✓xw
Enter Total Fan Flow CFM._K�x
v
in x .,. t..
3
Pass if Leakage Percentage ,< 6% [ 100 x (Line # 1) R- (Line # 2)]]
❑ Pass ❑ Fail
ALTERATIONS: Duct System and/or HVAC'Eguipment Change -Out"`'
4
Enter Tested Leakage Flow in CFM from CF 6R: Pre -Test of Existing Duct System Prior to
Duct System Alteration and/or Equipment Change -Out.
5
Enter Tested Leakage Flow in CFM: Final Test of New Duct System or Altered Duct System
�?
,
for Duct.S stem Alteration_and/or_E ui ment Chan e .Out;
6
EnteReduchori`in Leakage!for Altered Duct System"' [ . (Line &VA)Minus (Lige # 5)]
(Only if Applicable10
v "
7
Enter Tested Leakage Flo in CF" Outsid,�(Only if Applicable) _-_
_Y/a ✓
;.
8
Entire New, Duct System Pass if Leakage Percentage < 6% H;
; �... , .
❑ Pass ❑ Fail
100 x Line # 5 / Line:# 2 4
TEST OR VERIFICATION STANDARDS:; For Altered Duct System and/or HVAC Equipment Change -Out
✓ V/Use
one of the followin four Test or Verification Standards for coin Bance: ,
9
Pass if Leakage,Percentage; < 15% [100 x [2 (Line # 5) / r it, C- (Line:#•2)]]
ass ❑ Fail
10
Pass if Leakage to Outside Percentage < 10% [100 x [ (Line # 7) / (Line # 2)]]
❑ Pass ❑ Fail
Pass if Leakage Reduction Percentage > 60% [100 x [__(Line # 6) / (Line # 4)]]
11
❑pass ❑Fail
and Verification by Smoke Test.arid'Visual Inspection
Pass if Sealing of all Accessible Leaks and Verification by Smoke Test and Visual Inspection
❑ Pass ❑ Fail
Pass if One of Lines # 9 through # 12 pass
1
13Pass 0 Fail
INSTALLATION CERTIFICATE- °r
.(Page 4`of 12) Cf' '
Site Address P t Number
10
4.
INSTALLER COMPLIAN „E:STATEMENT"FOA DU T .LEAKAGE "
INSTALLER COMPLIANCE -STATEMENT
The building Was: ✓
LTest
ed atFinal' 13 -Tested t at Rou h -in •
•
_
INSS.TALLER VISUAL INSPECTION AT FINAL" CONSTRUCTION STAGE FOR NEW DUCTS:
12 Remove at least one supply and one'return register, and verify that the space's between the register boot and the interior finishing
wall are properly sealed .
Q If the house rough=in duct leakage test was conducted without an air handler installed, inspect the connection points between the
a handler and the supply and return plenums to verify that the connection pointslare properly -sealed. =
CkInspect all joints to ensure that no cloth backed, rubber adhesive duct tape is used on new ducts. "
s
✓ UCT LEAKAGE REDUCTION
Procedures or' veld v&i ication and diagnostic testing of air distribution s stens ar' available in'RACM, App6ydix RC4 3
NEW CONSTRUCTION:
Duct Pressurization Test Results�(CFM @ 25 Pa)
Measured
Values
1
Enter Tested Leakage Flow in CFM.
Fan Flow: Calculated.(Nominal:_✓ Cooling ✓ 0 Heating) or ✓ ❑ Measured'
' 2.
. If Fan Flow is Calculated as 400 cfm/ton x number of tons or as 21.7 cfm/(kBtu/hr) x Heating:
Capacity in Thousands of Btu/hr, enter total calculated or measured fan flow in CFM here:
✓ ✓
3
Pass if Leakage Percentage <,60/o for Final or < 4% at Rough -in without air handle:
❑pass ❑.Fail
100 x Line # 1 / Line # 2
ALTERATIONS:
Duct System and/or HVAC Equipment Change -Out
Enter Tested Leakage Flow in CFM from Pre -Test of Existing Duct System P'rio'r to Duct
4
System Alteration and/or Equipment .Change -Out. -• _
Enter Tested Leakage Flow in CFM from Final Test of New Duct System or Altered. Duct
G
5
System for Duct System Alteration and/or Equipment Change -Out.
Enter.Reduction in Leakage for Altered Duct System
-
6
Line # 4 ' Minus , Line 9'5 — '' Onl' if Applicable
7 :
Enter Tested Leakage,Flow: in CFM to Outside (Only if Applicable) j
✓ ✓
Entire New Duct System - Pass if Leakage Percentage < 6% for Final. `
8
.
100 x Line # 5 / Liner# 2
❑pass ❑Fail
TEST OR VERIFICATION STANDARDS: For Altered Duct Systemf And/or HVAC Equipment Change -
Out. Use one of the followin `four Test or Verification Standards for compliance:
9
Pass if Leakage Percentage, < 15%o [100 x [ V760 (Line # 5) / JCr�_: (Line # 2)]];
s';
®'lsass ❑Fail
10
- Pass if Leakage to Outside Percentage < 10% [100 k r (Line # 7) L (Line # 2)]]"
11Pass 1:1 Fail.*
Pass if Leakage Reduction Percentage >.60OXw[100 x L (Line ',# 6) % :'(Line #,4)]]
'pass
11
and Verification b Smoke Test and Visual. Inspection
❑ ❑Fail.
E
Pass if.Sealin of all Accessible Leaks. and Verif.1 b� Smoke Test'and Visual Ins ection❑Pass
01 Fail
1ication
• Pass if One of Lines # 9 through # 12 ass I
I 1
❑ Pass ❑ Fail
✓ ❑I;'the undersigned,` verify that the above•diagnostictest results were performed in conformance with the requirements for compliance
credit. I, the. undersigned, also certify that the newly installed or retrofit Air -Distribution System Ducts„Plenums and Fans comply with
Mandatory requirements specified in Section 1501(m) ofihe 2005 Building Energy Efficiency standards,
Instal ling;Subcontractor (Co. Name) OR.General Contractor.(Co'. Name) OR'Owne`r
2005, ,
Signa e:
Date: �� O
2005, ,