HomeMy WebLinkAbout043-730-0270
C)443 --7 2�O -027
043-730-027 05-1372
ROBERTS, MARCENA
38 LA PLACITA WY, CHIC SjVALE® .
Cont: MCCLELLAND AIR
REP HVAC
KENNICOTT CONST. CO. 240-70B ' f
Vents - 2/1-70P 257-70P
0�7�0 —OZ7 356-70E -
38 LaPlacita Way (LOT 7), Chico
(new single family) ��— = 7 p
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NOTES
RESIDENTIAL
PERMIT NO. 043-730-027 05-4372.:;.
ROBERTS, MARCENA
38 LA PLACITA WY, CHICO
Cont: MCCLELLAND AIR
REP HVAC
SPECIAL CONDITIONS
CHECKED
BY
SRA
FLOOD CERTIFICATE REQ.
FIRE SPRINKLERS REQ.
SPECIAL INSPECTION ITEMS
VERIFY
USE PERMIT CONDITIONS
SUB -STANDARD HOUSING LETTER
Eo�� oak � 0 -r - L iK c 41 I
4
:P
0 -,-.JOB FINALED (Date)
gnature
J=OK
0= Not OK
- = Not Applicable
. =Not Readyeady
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-Gmd-/ /Amp -Concrete
6. Gas; Location -Test -Wrap;-/ /" L'ft.
/ P Nat. or/ /" L "ft1 /LPG
7. Well Clearance & Disconnect
8. Utility Clearance
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
MOBILE HOME INSTALLATION (Plans) OK except #'s
1. Zoning Requirements -Setbacks -Easements
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-Connectoe
7. Water and Sewer Connected -C/O to Grade -HD Approval
8. Gas and Electricity Tagged
9. Tie Downs -Type -Installation Cert.
10. Exits; Insp.-Sketch
11. Cert. of Occupancy
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
Date PERMANENT END SYSTEM (ONLY)
1. Zoning Requirements -Setbacks -Easements
2. Footings; Size -Spacing -Marriage Line
3. Blocking
4. Gas; MH Test -Demand -Valve
5. Electricity; MH Test
6. Water, MH Test
7. Water and Sewer Connected
8. Gas and Electricity Tagged
9. Exits
10. License Decals
11. Verify #'s with Office
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
MISCELLANEOUS
Date DECKS, COVERS, CARPORTS, GARAGES (Plans) OK except #'s
1. Zoning Requirements -Setbacks -Easements
2. Footings; Soils -Size -Depth -Spacing -Connectors -Steel
3. Decks, Girders and/or Joists -Decking -Bracing -Stairs -Rails
4. Wood Awn.; Posts-Beams-Rftrs-Connectors
Shthg- Frg- Bracing
5. Alum. Awn.; Columns -Connections -Splice -Decal -Enclosures
6. Carports; Windows -Doors
7. Electric
8. Frmg.; Sills-Anchors-Studs-Rftrs-Trusses
9. Siding; Nailing -Veneer -Stucco -Mesh
10. Roof; Shthg-Roofing
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 #'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
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.; Grounding; Equip. w/5' Circulating Equip. -Pool Lghtg.
Boxes-Enclosures-Panelboards-Ins. to Main Conduit
9. Health Department Approval
10. Plumb.; Cir. Test -Water Supply Test
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 Applicable
= Not Ready
RESIDENTIAL (Single & Duplex)
Date UNDERFLOOR (Plans) OK except #'s
1. Zoning -Setbacks -Easements -Flood -Slope
2. Ftg., Main; Soils-Elec. Gmd.-/ /" Ftg. Depth
3. Ftg., Garage; Soils-Steel-Elec. Gmd.-/ /" Ftg. Depth
4. Ftg., Porches & Decks; Soils -Steel-/ /" Ftg. Depth
5. 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 -Fitting -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 Bolts-Joists-Vents-Crippies
15. Access & Ventilation
16. Insulation
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
PLUMBING (Permit) OK except #'s
17. Water Htr.; Vent -Access -Combustion Air Baffle
18. Water Pipe; Test & Anchor -Nail Protection
19. D.W.V.; Test Fittings & Anchor -Nail 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
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
ELECTRICAL (Permit) OK except #'s
24. Fixture & Transformer Clearance -Ins. Protection
25. Elec. Receptacles Spacing -Lights & Switches at Doors
26. Size Boxes & No. of Conductors Stapled
27. Romex Installed Close to Edge of Studs & C.J.
28. Equip. Ground made up w/Meth Fasteners -Bond Gas & Water
29. 2 Appliance Circuits in Kitchen & Conductor Size GFI
30. Subfeed Wire Size/ /ga. Cu or AI -AC. Wire Size/ /ga Cu or AI
31. Range Circle/ /ga Cu or AI -Oven Circ. / /ga Cu or Al
Insulated Neutral 0 Yes O 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 #'s
36. A.C. Ducts Insulation & Support
37. Vent Fan, Exhaust above insulation
38. Condensate Drain & Overflow, Size & Grade
39. Fumace-Vent Access -Comb. Ait-Return 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. Fire Stops, Furred Ceilings -Stairs -Chasers -Tubs
46. Headers & Beams -Size & Bearing
Date FRAMING (Continued)
47. Hangers -Post Caps -Anchors -Connectors
48. Cling. Joist-Rftr. Ties-Purlin-Roll Brac.-Truss-Shting.-Rtng.
49. Fireplace Ties or Type A Flue -Fireplace Throat Clearance
50. Attic Access; Size & Romex Protection -Draft Stop -Ins. Baffles
51. Bdrm. Windows or Exiting Doors -Sill Ht. & Dimensions
52. Garage Fire Protection Framing -RC Channel
53. Property Line Firewall & Openings
54. Ext. Doors -One 3' -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. Vents-Underflr. Access
59. Glazing Area -Glass Protection -Skylights -Plastic
60. Shear Walls; Nailing -Bolts
61. Brace Interior/Exterior Wall Panels
62. Insulation -Walls -Ceilings
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 & Rails
71. Fireplace or Stove, Clearance -Hearth
72. Elec. Outlets at Wood Panel, Int. & Ext.
73. Kit. Fixt. & Appliance; Ground -Air -Gap -Cooking Clearance
74. Elec. Outlets & Receptacles at Kit. Counter
75. Garage Fire Door, Swing -Landing -Closure
76. A.C. Duct in Garage -Damper
77. Wtr. Htr.; Vents -Clearance -Comb. Air Connector-P.R.V.
in Garage; Above Floor -Meth. Protection
78. Plb.; Elec. & Mech. Equip. Listed for Location
79. Elec. Receptacles in Garage (F.F.I.)-Romex Protection
80. Insulation -Foam -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 InstldJDrive 0 Yes O No/Walks O Yes 0 No /Planters 0 Yes 0 No
84. Stucco Brown -Finish
85. A.C. Unit Disconnect, Electrical -Plumbing
86. Vents Above Roof, Pibg-Appliance-Fireplace-Clearance to Openings
87. Water Well, Disconnect, Electrical, Plumbing
88. Exterior Elec. Trim, G.F.I. Receptacle -Underground
89. Ventilation Throughout House
90. Glass Protection
91. Corrections from Previous Inspections
92. Gas Test -Meters Tagged, Gas -Electric
93. Water & Sewer Connected -C/0 to Grade -HD Approval
94. Energy Compliance Certificate -Other Certificates
95. Address Posted
96. Fre 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) 638-71636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
PERMIT NO.
P0513.72
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 penally of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of Division 3 of
Issued Date: 05/25/2005 APN: 043-730-027-000
the Business and Professions Code, and my license is In full force and
effect.
License Class : T License Number.
Site Address: 38 LA PLACITA WAY. -CN
Date: Contractor:
Map Index:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the
Description: REPLACEMENT OF ROOFMOUNT HVAC
Contractors' State License Law for the following reason (Sec. 7031.5
UNIT
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
Owner: ROBERTS MARCENA C &PAULINE M
signed statement that he or she is licensed pursuant to the provisions of
the Contractor's Stale License Law (Chapter 9 commencing with Section
7000) of Division 3 of the Business and Professions Code) or that he or
38 LA PLACITA WAY
she Is exempt therefrom and the basis for the alleged exemption. Any
CHICO, CA
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).):
95928
❑ I, as owner of the properly, 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,
Applicant: ROBERTS MARCENA C &PAULINE M
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
38 LA PLACITA WAY
proving that he or she did not build or Improve for the purpose of
sale.).
CHICO, CA
l9r/ 1, as owner of the property, am exclusively contracting with
95928
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 5xempt under Article the Business and
/Pj�ofessions Code
Contractor: MCCLELLAND AIR CONDITIONING, INC
�J3�o%f
e.
5 '
_
Dale: - Owner: �'��� ___Lll
WORKERS' COMPENSATION DECLARATION
801 MARAUDER ST.
I hereby affirm under penalty of perjury one of the following declarations:
CHICO CA 95973
❑ I have and will maintain a certificate of consent to self -Insure for
workers' compensation, as provided for by Section 3700 of the
(530) 891-6202
Labor Code, for the performance of the work.for which this permit
is issued.
❑ 1 have and will maintain workers' compensation insurance, as
License #: 345121
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:
Architect:
Carrier
Engineer:
Policy #:
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
0 S. F.
become subject to the workers' compensation laws of California,
rotal Square Ft:
and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall
Valuation: $0.00
forthwith co ply with those provisions.
Census Code:
Date:
Applicant:
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.
%C� 60
CONSTRUCTION LENDING AGENCY
This permit is hereby Issued u9d r the applicable provisions of the Butte County Code and/or
I hereby affirm that there is a construction lending agency for the
is Issued 3097 CIV.)
ResoluZto do work Indic led bove for which fees have been paid. /.
""
performance of the work for which this permit (Sec
/ ". Date:��
Name:
�j
PERMIT EXPIRES ON:� [
Address:
Date
❑ 1 hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage,
handling and use of hazardous materials.
GI Notification in accordance with Section 1D827.5 of California Health & Safely 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 stale 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
•"buthorize representatives of ButteCounty u onn the a/lbov mentioned property for inspection purposes
l
/tooj�enter
Print Name:—=llf-1/�L--CJ�%G Signature:
Date: ;
`1�'Owner 0 Contractor 0 Agent for Owner 0 Agent for Contractor
�f
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT -
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
PERMIT N0,
1372
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 penally of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of Division 3 of
Issued Date: 05/25/2005 APN:O43-730-027-000
the Business and Professions Code, and my license is in full force and
effect.
License Class : License Number:
Site Address: 38 LA PLACITA WAY -CN
Date: Contractor:
Map Index:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the
Description: REPLACEMENT OF ROOFMOUNT HVAC
Contractors' State License Law for the following reason (Sec. 7031.5
UNIT
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
Owner: ROBERTS MARCENA C &PAULINE M
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
38 LA PLACITA WAY
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
CHICO, CA
applicant to a civil penalty of not more than five hundred dollars ($500).):
95928
❑ 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,
Applicant: ROBERTS MARCENA C &PAULINE M
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
38 LA PLACITA WAY
proving that he or she did not build or Improve for the purpose of
sale.).
CHICO, CA
/
ml( I, as owner of the property, am exclusively contracting with
95928
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.).
❑ 1 am 5xemptundeir Article 3 of the Business and P ofesstons Code
Contractor: MCCLELLAND AIR CONDITIONING, INC
Dale: 5 Owner.( �Q�
801 MARAUDER ST.
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
CHICO CA 95973
O 1 have and will maintain a certificate of consent to self -Insure for
workers' compensation, as provided for by Section 3700 of the
(530) 891-6202
Labor Code, for the performance of the work for which this permit
is issued.
❑ I have and will maintain workers' compensation insurance, as
License #: 345121
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:
Architect:
Carrier:
Engineer:
Policy #:
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
0 S. F.
become subject to the workers' compensation laws of California,
rotal Square Ft:
and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall
Valuation: $0.00
forthwith co ply with those provisions.
Census Code:
Date:
Applicant: r
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.
Go
CONSTRUCTION LENDING AGENCY --
—This permit is hereby issued ural r the applicable provisions of the Butte County Code and/or
I hereby affirm that there is a construction lending agency for the
Resolutio s to do work indic fed bove for which fees have been paid. /.
performance of the work for which this permit is issued (Sec 3097 Civ.)
Bf' Dater —(
Y
Name:
PERMIT EXPIRES ON:
Address:
(Date
❑ 1 hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage,
handling and use of hazardous materials.
❑+ Notification in accordance with Section 111827.5 of California Health & Safety Code is not applicable to the scheduled construction of this project.
O 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 stale 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 u on the ab o mentioned property for inspection purposes.
/t�oopenter
Print Name:/j�� ! �C/� Signature: 2Z&,
Dale:
Winer 0 Contractor ❑ Agent for Owner 0 Agent for Contractor
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATION
AND SUBMITTAL REQUIREMENTS
24 HOUR INSPECTION#: OROVILLE: (530) 538-7636 • CHICO: (530) 891-2834
OFFICE 9: (530) 538-7541
A FEE WILL BE REQUIRED AT TIME OFAPPLICA TION
Website: www.buttecounty.net/dds
"'PLEASE PRINT CLEARLY�X
APPLICANT NAME
CONTRACTOR
OWNER
�
Last Na
State
(�A(
City
Fi a
Address
Zip
It"l�
/,'
ICY
City
E-mail
Planner
State
t241
Class
Zip
qz
I,q
Phone
�c�D
Fax
J�
E-mail
APPLICANT NAME
CONTRACTOR
Name
�
Address
State
(�A(
City
Phone5b ,3 s Z 7a 9
State
Zip
Phone
Map Book
Fax
E-mail
Planner
Lic. #
Class
APPLICANT NAME
ARCHITECT/ENGINEER
Name
�
Address
State
(�A(
City
Phone5b ,3 s Z 7a 9
State
Zip
Phone
Map Book
Fax
E-mail
Planner
State License Number
APPLICANT NAME
Name /j r/ v
C:
Address q
�
Cityc.�
State
(�A(
Zip
7 0
Phone5b ,3 s Z 7a 9
Fax
E-mail)
Subdivision Name
APPLICANT SIGNATURE
X
For office use only:
Zoning
PrQpeO Ars f)4 e ,1 9
Z(f
Flood Zone
Cross Stree
& J&e XU5-
SRA
es
I No
Occ. I
Type Const. IAI
Subdivision Name
Map Book
Page
Lot #
Planner
Date Approved:
OVER FOR SUBMITTAL REQUIREMENTS
K:\FORMS\BUILDING FORMS\BldgApplSubRgmts.doc
PERMIT
BIN #
LOCATION
AP# T � 9
PrQpeO Ars f)4 e ,1 9
Z(f
City
/CCS
Cross Stree
& J&e XU5-
WORKER'S COMPENSATION
Policy Number
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
Descriro ption or Scope of Work:
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
required.
REQUEST FOR REFUNDS
Refunds can only be made upon written request by the person who
paid the fee. The request must be made prior to the expiration of the
permit and no construction work has been done. Filing fees, plan
check fees for work plan checked and other department costs are not
refundable.
Page 1 of 2
Received by: s> Amount: ��V • Bldg
Receipt #-43 J 7 s
C/ot ( �f V
Date: G�5
as
_
0
SRA
Sheriff
SMIP
Other
Total
REV 2-24-05
Im"