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HomeMy WebLinkAbout062-190-011(C BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT 24 HOUR INSPECTION #:(530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO) OFFICE #:(530) 538-7541 FAX#: (530) 538-2140 WEBSITE: www.buttecounty.net\dds FEE INFORMATION DBMSC Re -Roofing $144.50 Balance Due: $0.00 Receipt No: B3928 LICENSED CONTRACTOR'S DECLARATION I OWNER / BUILDER DECLARATION Contractor (Name) . State Contractors License No. / Class / Expires H -H CUSTOM BUILDING 299922 / B / 12/31/2006 I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am licensed under provisions of Chapter (cefull f ng wfecti,n 7000) of Dion 3 of the Business and Professions Code, and my license is in full ncing;�/�)////G//�A X 7/18/2007 Contractors Signature Date . WORKERS' COMPENSATION DECLARATION I 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 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 WORKER'S COMPENSATION INSURANCE, as required by Section 3700 of 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: State Fund Policy Number: 0786532 Exp. Date:1/1/2007 (This section need not be completed it the permitis foris for on�llars ($100) or eess.) ❑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 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 forthwith comply with those provisions. X 7/18/2007 Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR INSECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES. I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am exempt from the Contractor's License 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 pursuant to the provisions of the Contractors 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]; Please check one of the following: ❑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 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 that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proof that he or she did not build or improve for the purpose of sale.). aI, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (Sec. 7044, Business and Provessions Code: The Contractors License Law dows not apply to an owner of the property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors License Law.). ❑ I AM EXEMPT under Section B. 8 P.C. for this reason: IX y/.. 7/18/2007 Owners Signa ure Date CONSTRUCTION LENDING AGENCY I I HEREBY AFFIRM UNDER PENALTY OF PERJURY that there is a construction lending agency for the performance of the work for which this permit is issued. (3097 civ. code) Lenders Address City State Zip I 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 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 claims and liability for personal injury, including death, and property damage caused by, arising out of, or in any way connected with the issuance of this permit. I hereby acknowledge that issuance of this permit does not authorize the use or occupancy of any sidewalk, street, or subsidewalk. I hereby authorize representatives of Butte County to enter t e above mentioned property for inspection purposes. I hereby certify that I am the property owner r am authorized to act ony�a property owners behalf. 111...x,4 9—/_ _ �., 7/18/2007 ❑ Owner Contractor OR Agent for Owner ❑Agent for FILE COPY PROJECT INFORMATION Site Address: 8 OLD MILL RD Owner: Permit NO: B07-1555 APN: 062-190-011 WILLIAMS CLARENCE E, Permit type: MISCELLANEOUS P O BOX 474 Issued Date: 7/18/2007 By GLB Subtype: Re -Roof BIGGS, CA 95917 Expiration Date: 7/17/2008 Description: REROOF - 20 SQ (530) 682-2155 Occupancy: Zoning: TMl Contractor Applicant: Square Footage: H -H CUSTOM BUILDING H -H CUSTOM BUILDING Building Garage Remdl/Addn P O BOX 1341 P O BOX 1341 GRIDLEY, CA 95948 GRIDLEY, CA 95948 Other Porch/Patio Total (530) 846-0874 (530) 846-0874 FEE INFORMATION DBMSC Re -Roofing $144.50 Balance Due: $0.00 Receipt No: B3928 LICENSED CONTRACTOR'S DECLARATION I OWNER / BUILDER DECLARATION Contractor (Name) . State Contractors License No. / Class / Expires H -H CUSTOM BUILDING 299922 / B / 12/31/2006 I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am licensed under provisions of Chapter (cefull f ng wfecti,n 7000) of Dion 3 of the Business and Professions Code, and my license is in full ncing;�/�)////G//�A X 7/18/2007 Contractors Signature Date . WORKERS' COMPENSATION DECLARATION I 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 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 WORKER'S COMPENSATION INSURANCE, as required by Section 3700 of 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: State Fund Policy Number: 0786532 Exp. Date:1/1/2007 (This section need not be completed it the permitis foris for on�llars ($100) or eess.) ❑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 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 forthwith comply with those provisions. X 7/18/2007 Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR INSECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES. I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am exempt from the Contractor's License 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 pursuant to the provisions of the Contractors 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]; Please check one of the following: ❑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 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 that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proof that he or she did not build or improve for the purpose of sale.). aI, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (Sec. 7044, Business and Provessions Code: The Contractors License Law dows not apply to an owner of the property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors License Law.). ❑ I AM EXEMPT under Section B. 8 P.C. for this reason: IX y/.. 7/18/2007 Owners Signa ure Date CONSTRUCTION LENDING AGENCY I I HEREBY AFFIRM UNDER PENALTY OF PERJURY that there is a construction lending agency for the performance of the work for which this permit is issued. (3097 civ. code) Lenders Address City State Zip I 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 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 claims and liability for personal injury, including death, and property damage caused by, arising out of, or in any way connected with the issuance of this permit. I hereby acknowledge that issuance of this permit does not authorize the use or occupancy of any sidewalk, street, or subsidewalk. I hereby authorize representatives of Butte County to enter t e above mentioned property for inspection purposes. I hereby certify that I am the property owner r am authorized to act ony�a property owners behalf. 111...x,4 9—/_ _ �., 7/18/2007 ❑ Owner Contractor OR Agent for Owner ❑Agent for FILE COPY ., BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT APPLICATION OFFICE #: (530) 538-7541 FAX #: (530) 538-2140 A FEE WILL BE REQUIRED AT TIME OFAPPLICATION Website: w,,w.buttecounty.net/dds **PLEASE PRINT CLEARLY** APPVCANTSIGNAT03E X' =Qz /__' PERMIT NO. BIN # 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 DESCRIPTION OR SCOPE OF WORK: OWNER INFORMATION Last NameFi ' ` , ame c Mailing AdUss City City Ste State Zip Phone Cj Fax Fax E-mail Lic. # 2 APPVCANTSIGNAT03E X' =Qz /__' PERMIT NO. BIN # 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 DESCRIPTION OR SCOPE OF WORK: CONTRACTOR Name , Address D r' City /* Ste Zip Phone 0 Fax E-mail Cov Lic. # 2 Class APPVCANTSIGNAT03E X' =Qz /__' PERMIT NO. BIN # 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 DESCRIPTION OR SCOPE OF WORK: ARCHITECT/ENGINEER Name 1 Address D r' City /* State Zip Phone Fax E-mail Cov State License Number APPVCANTSIGNAT03E X' =Qz /__' PERMIT NO. BIN # 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 DESCRIPTION OR SCOPE OF WORK: APPLICANT INFORMATION Name' 1 S D r' Address /* Occ. a City State Sq FT- Living Garage Open Cov ❑ Structure Built without Permits ❑ Proposed Change of Occupanc� (Note previous use): Phone Fax E-mail APPVCANTSIGNAT03E X' =Qz /__' PERMIT NO. BIN # 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 DESCRIPTION OR SCOPE OF WORK: Zoning 1 S SRA I Yes I No Occ. Type Const. Sq FT- Living Garage Open Cov ❑ Structure Built without Permits ❑ Proposed Change of Occupanc� (Note previous use): For office use only: Zoning Flood Zone SRA I Yes I No Occ. Type Const.