HomeMy WebLinkAbout056-400-004r
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541 FAM (530)538-2140
WEBSITE: www.buttecounty.netWds
PERMIT NO.
BP043064
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of Division 3 of
Issued Date: 10/19/2004 APN• 056-400-004-000
the Business and Professions Code, and my license is in full force and
effect.
License Class: License Number:
Site Address:
Date: Contractor:
Map Index:
Description: ELECTRIC/CIRCUIT FOR WELL ONLY
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: COTTRELL MICHAEL EUGENE
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
1519 SO FIFE ST
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
TACOMA, WA
she is exempt therefrom and the basis for the alleged exemption. Any
98405_2642
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).):
XI, as owner of the property, or my employees with wages as their
sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors' State License Law does not apply to an
Applicant: COTTRELL MICHAEL EUGENE
owner of property who builds or improves thereon, and who does
such work himself or herself or through his or her own employees,
provided that such improvements are not intended or offered for
sale. If however, the building or improvements are sold within one
year of completion, the owner -builder will have the burden of
proving that he or she did not build or improve for the purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code. The Contractors' State License Law does
not apply to an owner of property who builds or improves thereon,
and who contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
Contractor:
❑ 1 am under Article 3 of the Business and Professions Code
Exempt
Date:/ Q /%� ^Z)Cwner: & &f �
WORKERS' COMPENSATION DECLARATION
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
License #:
workers' compensation, as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
❑ I have and will maintain workers' compensation insurance, as
Architect:
required by Section 3700 the Labor Code, for the performance of
the work for which this permit is issued. My workers' compensation
Engineer:
insurance carrier and policy number are:
Carrier:
Policy #:
Po
Total Square Ft: 0 S. F.
179 I certify that in the performance of the work for which this permit is
' \
Valuation: $0.00
issued, I shall not employ any person in any manner so as to
Census
become subject to the workers' compensation laws of California,
Code:
and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions.
Date: /o — ",—
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.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
This permit is hereby issued under the applicable -provisions of the Butte County CodR and/or
Resolutions Ao dejjirk indicated above for which fees have been paid.
performance of the work for which this permit is issued (Sec 3097 Civ.)
J
Name:
B 6
Y /\ D te: V
b 1
Address:
PERMIT EXPIRES ON:
Date
❑ I hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage,
handling and use of hazardous materials.
❑ Notification in accordance with Section 19827.5 of California Health & Safety Code is not applicable to the scheduled construction of this project.
❑ Attached are copies of the required E.P.A. notification forms.
I hereby certify that I have read this application, that the above information is correct, and that I am the owner or the duly authorized agent of the owner. 1 agree to comply with
all county and state laws relating to building construction. I acknowledge it is unlawful to alter the substance of any official form or document of Butte County. I hereby
authorize representatives of Butte County to enter upon the above) mentioned property for inspection purposes.
Print Name: f Y ,O—V, A e— L � � n'(-11�� ` I Signature:
Date: 10—IC? —& 4
}L>\Owner 13 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 #: (530) 538-7541
A FEE WILL BE REQUIRED AT TIME OFAPPLICA TION
"PLEASE PRINT CLEARLY"
OWNER
Last Name /[First
'o
Name
Addrsssi 4S Rb A C, 14 -J4-
Cityctt (c o I
St e i t -t F
p,
Zip, S% 3
�1
`2no ^9'1 _ (3 D
Fax
E-mail
i
IN 114M,
For office use only:
CONTRACTOR
Name
C%j A) F
Address
City
State
Zip
-Phon
a
E-mail
Lic. #
Class
i
IN 114M,
For office use only:
ARCHITECT/ENGINEER
Name
�j r,
Address
City
Occ..
State
Zip
Phone
I00]�D
Fax
E-mail
Date Approved:
State License Number
i
IN 114M,
For office use only:
APPLICANT NAME
Name
Flood Zone
AddreF4 I
City, 14 \c -n
Occ..
St
3 -TO
Phong 3,D J01
I00]�D
Fax
E-mail
Date Approved:
i
IN 114M,
For office use only:
Zoning
P perry Address
Flood Zone
SRA
Yes
T No
Occ..
Type Const.
Subdivision Name
Map Book
Page
Lot #
Planner
Date Approved:
PERMIT
NO.
BP
BIN #
LOCATION
P perry Address
City
Cros
WORKER'S COMPENSATION
Policy Number
Carrier
Nhiring anyone other than license contractors, a certificate of worker's
compensation must be shown at the time of permit issuance.
LENDING AGENCY
-Nam
Address
De*ription or cope of Wo
l c tA -r Ddi� rho, U-sE-
R-LA� IJ
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
OVER FOR SUBMITTAL REQUIREMENTS
K:\FORMS\BUILDING FORMS\BldgApplSubRgmts.doc Page 1 of 2
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.
Receipt #:
Date)
Amount:
SRA
Sheriff
SMTP
Other
Total
REV 7-27-04
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 BE ACCEPTED. ALL PLANS MUST BE LEGIBLE AND IN INK
❑
1.
Site plans, 3 or 4 sets, signed by the preparer of the plans. No graph paperl
❑
2.
Complete plans, 3 or 4 sets, signed by the preparer of the plans (No graph papers) 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. (Note: Not required for additions to
mobile or modular homes.)
❑
5.
Statement of Intent for Non -heated and A/C for Non -Residential Buildings.
❑
6.
Manufactured homes: (A) Data sheets and installation inst, (B) Marriage line info, (C) Floor Plan, (D) Tie down
or fnd plans, all in duplicate.
❑
7.
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).
EJ _13—Sanitation md-site-pJan-approyae-EmdronmentaLHealth_Depadment_
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, ❑ Letter from Legal Owner (for 433A's).
If you have questions or would like additional information regarding this process, contact a Permit
Application 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
KAFORMS\BUILDING F0RMS\B1dgApp1SubRgmts.doc Page 2 of 2 REV 7-27-04
1:.
9
O.B.-1
L RV Rim
Attention Property Owner: ,
An "owner -builder" building permit has been applied for in your name and bearing your
signature.
Please complete and return this information at your earliest opportunity to avoid
unnecessary delay in processing and issuing your building permit. No building permit will
be issued until this verification is received.
1 I personally plan to provide the major labor and materials for construction of the
proposed property improvement: YES(,• NO[ ].
2. I HAVE HAVE NOT[ ] signed an application for a building permit for the
proposed work.
I have contracted with the following person (firm) to provide the proposed
construction:
NAME:
ADDRESS: CITY:
PHONE: CONTRACTOR'S LICE;\TSE NO.
4 I plan to provide portions of this work, but I have hired the following person to
coordinate, supervise, and provide the major work:
NAME:
ADDRESS: CITY:
PHONE: CONTRACTOR'S LICENSE NO.
I will provide some of the work but I have contracted (hired) the following persons to
provide the work indicated:
NAME ADDRESS PHONE TYPE OF WORK
IGNED:
'PROPERTY OWNERJLIII,�—�A —A"—
IAL EC
DATE: O I ov-- n `t
NOTE: This owner -Builder Verification is required by Section 19831 and
19832 of the California Health and Safety Code.,
This verification must be completed and returned to our office before
we are permitted to issue the permit.
May 1995 226
n
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
property improvements specified
For your protection, you should be aware that as "owner -builder" you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are personally
performing their own work If your work is being performed by someone other than yourself'; you may protect
yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all permits
for which they apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you
should be aware of the following information for your benefit and protection: I\-
0 If you employ or otherwise engage any persons other than your immediate family, and the work (including
materials and other costs) is $300 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
0 If you are an employer, you must register with the State and Federal Governments as an employer and you are
subject to several obligations including state and federal income tax withholding, federal social security taxes,
workers compensation insurance, disability insurance cow, and unemployment compensation contributions.
0 There may be financial risks for you if you do not carry out these obligations, and these risks are especially
serious with respect to worker's compensation insurance.
0 For more specific information about your obligations under Federal Law, contract the Internal Revenue
Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your
obligations under State Law, contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale, propertyowners who are -not licensed contractors are allowed to
perform their work personally or through their own employees, without a licensed contractor or subcontractor, only
under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "ownerbuilder"
building permit, erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing their own
work personally.
Information about licensed contractors may be obtained by contracting the Contractors State License
Board in your community or at 1020 N Street, Sacramento, CA 95814.
Please complete the "Owner Builder Verification" on the reverse side of this form so that we can confirm
that you are aware of these matters. The building permit will not be issued until the verification is returned
C. Vie* C.B.O.
, Building Inspection
NOTE: This Owner -Builder Information is required by Section 19830 of the California Health and Safety Code.
May 1995 2.27