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HomeMy WebLinkAbout062-340-0171 62-34-17 Tom Luper NkS Sugar Pine Dr., @ Madrone Way, lot 73, Ponderosa Pines Sub,Berry Cr. Perm #2622-80B,P,E,M(new single family 62-34-17 Permit#2016-84 .B (1st renewal/2622- 80) 62-3 17 Fi f9a► Robert D. Schoenstei E S Sugar Pine Dr , @ Madrone Way, Berry Creek , Permit #4567=81111-P,E;M(transfer of " ownership or permits 2622-80 & ^2016-81� 62-34-17 P` mit#3199-82B(2nd renewal/2622-80) Mar, COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS } 7 County Center Drive - Oroville, Catifornia 95965 - Telephone 916/534-4541 APPLICATION AND PERMIT -?/ '] PERMIT NO. 'S J ASSESSOR PARCEL NUMB ZONING - —Z BUILDING PERMIT ow TEL PHONE OWNER'S MAILING ADDRESS� � (C^ ►- SO. FT. OCC. BUILDING VALUATION CONTRACTOR'S NAM �n Y\ TELEPHONE CONTRACTOR'S MAILING ADDRESS Fireplace CONSTRUCTION LENDER t`7v� UNKNOWN : Total Valuation Is Filing Fee $ 10.00 LENDER'S MAILING ADDRESS Permit Fee / a-. $ qtm ARCHITECT OR ENGINEER ` LICENSE NO. Plan Checking Fee $ Penalty $ ARCHITECT OR ENGINEER'S MAILING ADDRESS Permit fee $ , 00 BUILDING DDRESS� I PLUMBING PERMIT Filing Fee 10.00 Each Trap 2.00 Solar Water Heater 20.00 Water piping 5.00 LOT NO. SUBDIVISION NAME P RCEL MAP Each qas water heater or vent 5.00 Gas piping system 1 - 5 outlets 5.00 � USE OF STRUCTURE SF L�,� Duplex ❑ Mobi lehome ❑ Other SPECIFY Building sewer 5.00 Mobile Home JSJG1W1 10-00e TYPE OF WORK New ❑ Addition[] R eel ❑ Uti lities Installation[] Other rA21,� Describe work: t a-- �6� �� Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 10.00 Main service 0ov OR LESS 1 100 AMP OR LESS 10.00 Main Service EA. ADO'L 100 AMP 2.50 NEW CONST. // DWELLING OCCUP.& OR ADDNS. l ACC. BLDGS. 1 2/20sgft CONTRACTORS LICENSE LAW I declare under penalty of perjury (Check one): ❑ I am licensed under provisions of Chapt. 9, Div. 3 of the BUSIneSS and Professions Code and my license is in full force and effect. License No. Classification I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONSTR ( MULTI -OUTLET NON-RESID `BRANCH CIRCUITS) 2.50 ea NEW CONSTR POWER APPARATUS & NON-RESID. SINGLE OUTLET CIR. EX. OCCUp(OUTLE7S OR FIXTURES 2A L@g3oQ FIXED APPLNS. OR EX. Occup. OUTLETS (RESID,) EA.) 1 2.00 Temporary service 10.00 Mobile Home Facilities 15.00 Misc. Wiring 15.00 Permit Fee $ Contractor MECHANICAL PERMIT FiIingFee 10.00 WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. I shall not employ any person in any manner so as to become subject to the W. C. laws of California. Noti a to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Heating Cooling Hood 3.00 Ventilation permit Fee $ Contractor 1 certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the County of Butte to enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the County of Butte against all liab' ' ies, judgments, costs, and expenses which may in any way accrue agains sa County ' onsequence of ing of this permit. X Date Signature of Applicant — %OWner atiContractor ❑ Agent ❑ An OSHA pe -mit is required for cavons over 5'0" deep and demolition or construct- ion of structures/3 stories in height. Mobile Home Installation Fee $ TOTAL PERMIT FEE $ OCCUP. GROUP I TYPE OF CONST. PARCEL PD HD ISSUE This permit is hereby issued under sions of the Butte County Code and/or work indicated above for which C 0 OF PUBLIC Iover By � � PERMIT EXPIRES ate the applicable provi- resolutions to do fees have been paid. WORKS Date Receipt No. /c� � WHITE-D.P.W.. YELLOW -ASSESSOR, PINK -INSPECTOR, GOLDENROD -APPLICANT COUNTY OF BUTTE - Department of Public Works 7 County Center'Drive, Oroville, CA. 95965 Phone: 916-534-4541 OWNER -BUILDER VERIFICATION 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 in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your build- ing 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 or no) j4.Q$ 2. I (have/have not)- signed an application for a building permit for the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction: Name N t Address City Phone .,Contractors License No. 4. I plan to provide portions of this work, but I have hired the following person to coordin ,, ,,,�pervise, and provide the major work: Name �f1vv-- DD��''�`�^ ..Address City Phone Contractors License.No. 5. 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 0 Signed: Qk,3k ' Property Owner Social Security numb Date Z (e ar NOTE: This Owner -Builder Verification is sent to you as required by Sections 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. COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS 7 County Center Drive - Oroville, California 95965 - Telephone 916/534-4541 APPLICATION AND PERMIT PERMIT NO. �7 r A A ASSESSOR PARCE UMB �p�� —/'' ZONING BUILDING C&M& OWNER R686-;0- '. SG14OCA/STE/�(l TELEPHO X89- ��� -SQ. FT. OCC. B ILDING VAL N O R'S )LINGyomoi/' DDRESS CT4 � /vscz„ ^I'f`J•/e C+ CONTRACTOR'S VV /� TELEPHONE CONTRACTOR'S MAILING ADDRESS Fireplace CONSTRUCTION LENDER T UNKNOWN Total Valuation $ Filing Fee $ 10,00 LENDER'S MAILING ADDRESS Permit Fee $ ARCHITECT OR ENGINEE LICENSE NO. Plan Checking Fee $ Penalty $ ARCHITECT OR ENGINEER'S MAILING ADDRESS Permit fee $ /0.00 BUS s ADDRESS n e, A/C PRIUIS PLUMBING PERMIT Filing Fee 10.00 M niTDEC fE w �/ /.i /V /% Each Trap 2.00 Repair drainage or vent piping 5.00 Water piping LOT NO. SUBDIVISION NAME PARCEL MAP Each qas water heater or vent 5.00 Gas piping system 1 - 5 outlets USE OF STRUCTURE SF Duplex❑ Mobilehome❑ Other SPECIFY Building sewer Lawn sprinkler sy tem 5.00 / TYPE OF WORK New ❑ Addition ❑ RerpodeI ❑ Uti lliitiJes [J rInstal lation ❑ Other Describey _work: """�,�G� v (/ 262 157- Permit Fee $ „O Contractor ELECTRICAL PERMIT Filing Fee 10.00 Main service 100 AMP ORSLESS 5.00 Main service EA. ADD'L 100 AMP 2,50 NEW CONST. (DWELLING OCCUP.m\ OR ADDNS. ACC. BLDGS. / 20 sq it CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): ❑ I am licensed under provisions of Chapt. 9, Div. 3 of the Business and Professions Code and my license is in full force and effect. License No. Classification I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NON-RES'..NEW CONSTR. BRANCH CMULTI-OUIRCUITS 2.50 ea NEw NONCONSTFL R ESID. SINGLE OUTLET CIR. / POWER APPARATUS s1 . Ex. OccupOUTLETS OR FIXTURES 50@250 BAL@1 Ex. Occup.(ouTL111E 'ETSP(RESID )REA.) 2.00 Temporary service 10.00 Mobile Home Facilities 15.00 Misc. Wiring 7 16.4W6 ++L50 Permit Fee $ O Contractor MECHANICAL PERMIT FiIingFee 10.00 WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. to the W. C. laws of California. NorI shall not employ any person in any manner so as to become subject 1ce Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shal I be deemed revoked. Heating Cooling Hood 3.00 Ventilation permit Fee S Q Contractor I certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating. to building construction, and hereby authorize representatives of the County of Butte t0 enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the County of Butte against all liabilities, judgments, costs, and expenses which may in any way accrue again i County 'n onsequence of the granting of this permit. X Date_:(Z � Signature of Applicant — Owner Contractor ❑ Agent ❑ An OSHA permit is required for excavations over 5'0" deep and demolition or construct- ion of structures over 3 stories in height. Mobile Home Installation Fee $ TOTAL PERMIT FEE $ 0 OCCUP. GROUP I TYPE OF CONST, JPARCEL[ PD No I ISSUE This permit is hereby issued under sions of the Butte County Code and/or work indicated above for which fees DIRECT OF PUBLIC By PER EXPIRES Date the applicable provi- resolutions to do have been paid. WORKS Date _ r�� Receipt No. 5854- 6 WNITE-D.P.W., YELLOW -ASSESSOR, PINK-INSPEC70R, GOLDENROD -APPLICANT COUNTY -OF 'BUTTE - Department of Public Works 7 County Center Drive, Oroville, CA. 95965 Phone: 916-534-4541 OWNER -BUILDER, VERIF ICAT ION 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 in the envelope provided at your . earliest opportunity to avoid unnecessary delay in processing and issuing your build- ing 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 or no) `S 2. I (have/have not) "IM—. signed an application for a building permit for the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction: Name &10&) Address City Phone Contractors License 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 0 o &it Address City Phone Contractors License No. 5. 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 Signed : Property Owner Social Security number Date lez, 4 NOTE: This Owner -Builder Verification is sent to you as required by Sections 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. cbwaT4 L -L TO -u3 IoM T -r CAP ----------- tlo oe.0 -TO- V-13 ow N.Ab lt--- 17c� •©►�tAiN t _t5 __�-i.E' As _ .�? SA% �x�il�t�i A (o.22-780(5 -p .) + AN T_ p Tf-QuesTitil q 4r e 7' T k COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS - BUILDING DIVISION 7 COIJINTY CENTER DRIVE.- OROVILLE, CALIFORNIA 95965 - TELEPHONE: 916/534-4541 PERMIT APPLICATION DATA SHEET ��,r� / Permit No. OWNER r�FF D 5 � ��KJ A. P. No. 60-34-17 Proposed Building Use TJicJSFCoe_-, Permit Fee Based: % Complete Contract Price DPW Valuation Other (Explain) Building Inspector _--------'`!`may Date At time permit application, I was advised the following data must be submitted prior to permit processing and/orsuance: DATE RECEIVED APPROVED 11. All items have been submitted. . . . . . . . . . . . 2. Plot plans in duplicate./triplicate. . . . . . . . . . . 3. Complete plans in duplicate./triplicate. . . . . . . . . 4. Complete engineered plans and calcs. . . . . . . . . . 5. Plans with Energy Design Compliance Statement. . . . . . 6. State Energy Forms No. 7 Statement of Intent for Non -Heated and AC Buildings. 8. Fees of $ . . . . . . . . 9. Letter of signature authorization. . . . . . . . . . . 10. Sanitation approval from Health Dept. . . 11. Planning approval for (A) Use: (B) Parking: 12. Certificate of Workmen's Compensation Insurance. . . . . 13. Contractor's License Information (no., name style, classif.) 14. Owner -Builder Verification (Given to owner❑, Mail to owner ❑ ) 15. Improvements may be required. . . . . . . . . . . . 16. Mobilehome Installation Data. . . . . . . . . . . Pre-Inspec. request to 17. Pre -Inspection for Required. Building Inspector (Date) 18. Other Whenyou Issue the permit, process as follows: Mail to owner. Mail to contractor. 1/ Telephone and�hold for pickup at �y office. Deliver w/inspector. Other ? Applicant�Date Copy of plans sent - Health Dept., .Fire Dept., Other Date During the plan checking process, the following data must be submitted prior to permit issuance. (For required items not checked above at time of application, circle item.) 1. Index permit for above Items No. 2. Additional items required: (Contractor, Designer, Owner) was advised of above required data by Telephone Mail By Plans checked by Date Plans approved by Date Other Copy—DPW Date Other COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS ' 7 County Center Drive - Oroville, California 95965 - Telephone 916/534-4541 APPLICATION AND PERMIT PERMIT NO. ASSESSOR PARC L NUMBER Y///L/ 3 ZONING BUILDING PERMIT OWNER- LUp6� TELEPHONE 5 _ZG J/ V SQ. FTs. OCC. BUILDING VALUATION ALUATION�n" R'S G ADDRESS S�er COa �4 � CONTRACTOR'S NAME 0 TELE ONE CONTRACTOR'S MAILING ADDRESS Fireplace CONSTRUCTION LENDER UNKNOWN Total Valuation Is Filing Fee $ 10.00 LENDER'S MAILING ADDRESS Permit Fee Z $ : d ARCHITECT OR ENGINEER LICENSE NO. Plan Checking Fee _$ Penalty $ ARCHITECT OR ENGIN'EER'S MAILING ADDRESS Permit tee $ pv BUILDING/ADDRESS � P/ _ /6 be. ���� /� c-_16 /U /Vl PLUMBING PERMIT Filing Fee 10.00 !9' y , Each Trap 2.00 Repair drainage or vent piping 5.00 136 Water piping LOT NO. %3 SU!LDIV��IS//ION NAME , rr /, PARCEL MAP A�it//��`��.!09L 0WN s S(ia J�Q" Z Each qas water heater or vent 5.00 Gas piping system 1 - 5 outlets USE OF STRUCTURE SF Duplex❑ Mobilehome❑ Other SPECIFY Building sewer Lawn sprinkler system 5.00 TYPE OF WORK New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation❑ Other Describe work: 11 L.s7- � �r' �o �Q Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 10.00 Main service 600v OR LESS 5.00 100 AMP OR LESS Main service EA. ADD'L 100 AMP 2.50 NEW CONST. DWELLING OCCUP.61 20 sq ft OR ADDNS. ACC. BLDGS. I CONTRACTORS LICENSE LAW I declare under penalty of perjury (Check one): ❑ I am licensed under provisions of Chapt. 9, Div. 3 of the Business and Professions Code and my license is in full force and effect. License No. Classification I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONSTR (MULTI -OUTLET 2,50 ea NON.RESI D. BRANCH CIRC ITS NEW CONSTR ( POWER APPARATUS 61 NON-RESID. SINGLE OUTLET CIR. Ex. OCCUp OUTLETS OR FIXTURES 5B L25 FIXED APPLNS. OR EX. OCCUp.�OUTLETS (RESID.) EA. 2.00 Temporary service 10.00 Mobile Home Facilities 15.00 Misc. Wiring 7.50 Permit Fee $ ' Contractor MECHANICAL PERMIT FiIirig Fee 10.00 WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. ® I shall riot employ any person in any manner so as to become subject to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith Comply with such provisions or this permit shal I be deemed revoked. Heating Cooling Hood 3.00 Ventilation Permit Fee $ Contractor I certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the Countyot Butte to enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the County of Butte against all liabilities, judgments, costs, and expenses which may in any way accrue against sai ounty i onsequence of the granting of this permit. �� Date G_�_ &-/ Signature of Applicant — Owner s� t.ontractor ❑ Agent ❑ An OSHA permit is required for excavations over 5'0" deep and demolition or construct- on of structures over 3 stories in height. Mobile Home Installation Fee $ TOTAL PERMIT FEE $ S , o d OcCUP. GROUP , I TYPE OF CONST. I PARCEL I PD ND SSUE This permit is hereby issued under the applicable provi- si s f the Butte County Code and/or resolutions to do ork ndicated above for which fees have been paid. 1R CT-QQ OF PUBLIC WORKS 1 Date PERMIT EXPIRES Date 4" �- Z— Receipt No. %//3 WHITE-D.P.W., YELLOW -ASSESSOR, PINK -INSPECTOR, GOLDENROD -APPLICANT COUNTY OF BUTTE - Department of Public Works 7 County Center Drive, Oroville, CA. 95965 Phone: '916-534-4541 OWNER -BUILDER VERIFICATION 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 in the envelope provided at your. earliest opportunity to avoid unnecessary delay in processing and issuing your build- ing 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 or no) 2. I (have/have not) signed an application for a building permit for the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction: Name e rx Q Address City. Phone Contractors License No. 4. I plan to provide portions of'th'is work, but'I have hired the following person to co rdinate, supervise,'and provide the major work: Name Address City Phone Contractors License No. 5. I will provide some persons to provide Name A of the work but I have contracted (hired) the following the work indicated: S igned : Property Owner,_ Social Security' numb Date t/, -:92- 01 ss Phone -Type of Work r NOTE: This Owner -Builder Verification is sent to you as required by Sections 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. COUNTY OF BUTTE DEPARTMENT OF PUBLIC WORKS 196 Memorial Way, Chico — Phone: 891-2751 7 County Center Drive, Oroville — Phone: 534-4541 Skyway and Elliott Road, Paradise — Phone: 872-2961, Ext. 57 CORRECTION NOTICE Q BUILDING OR PROPERTY ADDRESS A routine inspection indicates that the following violations of County Ordinance exist at the above address and should be corrected. Please notify this officek when correction of work is completed. If you have any question pertaining to this matter, or need additional explanation, please contact this office immediately. { 0 ,xa H 1W .V Q+2;;- A . pC� T -am ,ate Q -a -c Y��-Y -7---, InsP ector o- Q'I'J'111; T Date " COUNTY OF BUTTE DEPARTMENT OF PUBLIC WORKS 196 Memorial Way, Chico — Phone: 891-2751 7 County Center Drive, Orovi Ile — Phone: 534-4541 Skyway and Elliott Road, Paradise — Phone: 872-2961, Ext. 57 CORRECTION NOTICE BUILDING OR PROPERTY ADDRESS 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. o R Rr rte?Gr•:. ALL- ►�C e� �... Grp/f!S Inspector /` LiDate`� � f 3t��-sem f PERMIT NO. - 1B,P E,M mixTRA�S �S - 0 & 2016-81 ren . { PERMIT EXPIRES OWNER Robert Schoenstein CONTR. owner f • + ASSESSOR PARCEL 62-34'17 1 ! LOCATION E/S Sugar Pine Dr., @ Madrone Way, Berry Creek + 1 E� 1 � 1` Temp. Power Pole - # Called PG&E , Temp. Elec. Service . Called PG&E Temp. Gas Service I Called PG&E JOB FINALED (Date) f Signature 1a1, 4 1 , 1 0 = Not OK - = Not Applicable MOBILEHOMES MISCELLANEOUS = Not Ready Date MOBILEHOME UTILITIES (Plans) OK except H's 1. Zoning Requirements -Setbacks -Easements Date DECKS, COVERS, CARPORTS, ETC. (Plans) G., accept 9 1. Zoning Requirements -Setbacks -Easements 2. Soils; Special MH Support -Sketch _ 2. Footings; Size -Depth -Spacing -Connectors 3. Sewer; Location -Test -Fall -C/0 -Concrete _ 3. Decks; Girders and/or Joists -Decking -Bracing -Stairs -Rails 4. Water; Location -Test -Easement Needed (Sketch) 4. Wood Awn.; Posts-Beams-Rftrs.-Connec.-Shthg.-Rfg.•-Bracin_g_ 5. Electricity; Location-Clearances-Grnd.-/ / Amp -Concrete 5. Alum. Awn.; Columns-Connections-Splice-Decal-Enc.os„res 6. Gas; Location -Test -Wrap:/ /"L"ft./ /"Nat. or/ /"L"ft./ /"LPG 6. Carports; Windows -Doors._ 7. Utility Clearance 7. Elec. Card -BI Date Card -BI Date Card -BI Date Card -BI Date Card -BI Date Date Card -BI Date MOBILEHOME INSTALLATION (Plans) OK except H's 1. Zoning Requirements -Setbacks -Easements Card -BI Date _ Date Card -BI Date POOLS (Plans) OK except N's v 1. Setbacks -Easements 2. Footings; Size -Spacing -Marriage Line 2. Soils; Compaction -Structure Stability 3. Gas; MH Test -Demand -Valve -Connector 3. Pool Structure; Steel -Connections -Thickness -Dead Men -Lining _ 4. Electricity; MH Test -Crossovers -Breakers -Clearances 4, Elec.; Receptacles and Lighting; Distances-GFI 5. Drain; MH Test -Fall -Flex Connector 5. Elec.; Pool Lighting; 15 volts-GFI 6. Water; MH Test -Regulator -Connector 6. Elec.; Enclosures; Conduit Entries -Terminals -Listed 7. Water and Sewer Connected -C/O to Grade -HD Approval 7. Elec.; Bonding; Metal w/5' -Circulating Equipment -Heater 8. Gas and Electricity Tagged 8. Elec.; Grounding; Equip. w/5' -Circulating Equip. -Pool Lghtg. Boxes -Enc losures- Pane Iboards- Ins. to Main in Conduit 9. Exits; Insp.-Sketch 10. Cert. of Occupancy 9. Health Department Approval 10. Plumb; Cir. Test -Water Supply' Test Card B -I Date Card -BI Date Card -BI Date Card -BI Date Card B-1 Date Card -BI Date Card -BI Date Card -BI Date V = OK 0 = Not OK - = Not Applicable * = Not Ready RESIDENTIAL (Single and Duplex) Date UNDERFLOOR (Plans) OK exce t#'s Date FRAMING (Continued) 1. Zoning requirements -Setbacks -Easements 48. Property Line Firewall & Openings 2. Ftg., Main; Soils-Steel-Elec. Grnd.- / /" Ftg. Depth 49. Ext. Doors -One 3' -Check Garage -3rd story, 2 exits 3. Ftg., Garage; Soils -Steel- / /" Ftg. Depth 50. Stairs; Width -Headroom -Rise -Run -Landing -Fire Protection 4. Ftg., Porches & Decks; Soils -Steel- / /" Ftg. Depth 51. Plywood on Roof Overhang -Attic Vents -Rafter Outriggers 5. Stemwalls, Main; Steel-Blockouts-Wrapped-Slab 52. Siding -Nailing -Veneer 6. Stemwalls, Garage; Steel-Blockouts-Wrapped-Slab 53. Stucco Mesh -Drip Screed-Fdn. Vents-Underflr. Access 7. Piers -Fireplace Ftg.-Steel 54. Glazing Area -Glass Protection -Skylights -Plastic 8. D.W.V.: Fall -Fittings -Test -2 way C/O -Sewer Test 55. Shear Walls; Nailing -Bolts 9. Gas Pipe; Size -Anchors 10. Water Pipe; Test -Anchors -Regulator -Service Test 11. Electric; Underground 12. Plenums & Ducts; Clearance -Material -Support -Ins. 13. Girders -Sills -Anchor Bolts -Joists -Vents -Cripples Card -BI Date Card -BI Date Card -BI Date Card -BI Date Card -BI Date Card -BI Date Card -BI Date Card -BI Date Date A tans) OK except #'s Card -BI Date Card -BI Date Date PLUMBING (Permit) OK except p's 4j Ext. Steps -Door & Sidelight Protection -Landings a Detector _ 14. Water Ht.; Vent -Access -Combustion Air Furnace' - learance-Comb. Air -Connector - Above Floor-Ducts-Mech. Protection 15. Water Pipe; Test & Anchors -Nail Protectionarage; 16. 17. D.W.V.; Test-Fttngs & Anchors -Nail Protection Shower Pan; Test, First Floor -Tub Access Bed oom Exiting F.I. & Bath Fixtures & Tub Access 18. Test Tub & Shower, 2nd Floor -Tub Access Elec. Trim & Subpanel; Breaker Sizes -Labels 19. Gas Pipe; Size & Anchors tairs & Rails fireplace or Stove; eara art 64. Elec. Outlets at Wood Panel; Int. & Ext. Card -BI Date Card -BI Date JS--KiY. Fixt. & Appliance; Grnd.-Air Gap -Cooking Clearance Card -BI Date Card -BI Date Alec. Outlets & Receptacles at Kit. Counter Date ELECTRICAL Permit OK except p's 6 .-&"e-Damper ge tre Door; Swing -Landing -Closer 20. Fixture & Transformer Clearance -Ins. Protection 6 Htr.; Vents -Clearance -Comb. Air -Connect - 21. Elec. Receptacles Spacing -Lights & Switches at Doors i8�plb., Elec. &Mech. Equip. Listed for Location 22. Size Boxes & No. of Conductors -Stapled 71. .I.)-Romex Protec. 23. Romex Installed Close to Edge of Studs & C.J. 24. Equip. Ground made up w/Mech. Fasteners -Bond Gas & Water nsution -Foam -Looked in Attic ❑Yes lalatio 25. 2 Appliance Circuits in Kitchen &Conductor Size rtxn. uars &Deck Construction -Post Caps _ 26. Subfeed Wire Size / / ga. Cu or AI-A.C. Wire Size'/ / ga. Cu or Al Vents & Crawl Hole tf Drainage & Wood -Earth Clearance Looked under Floor es 27. Range Circ. / / ga. Cu or AI -Oven Circ. / / ga. Cu or At, Insulated Neutral ❑Yes EJ No 75. Following instld.: Drive E); Yes Walks El Yes No; Planters ❑Yes P<o 28. Service -Riser Conductors & Ground -Main Disconnect 7 - 29. Equip. Clearances; Panels-Motors-Mech. Equip. -77, Unit; Disconnect-Clrnces-Brkr. & Cond. Size -115V Outlet 30. Clothes Closet Light -Shower Light U"o'VPAts Above Roof; Plbg.-Appliance-Firepl.-Clearance to Opngs. Water Well; Disconnect, Electrical, Plumbing $6'- EDior Elec. Trim; G.F.I. Receptacle -Underground Card B-1 Date Card BI Date 43 tilation throughout House Card B -I Date Card -BI Date Gla Protection orrections from Previous Inspections Date MECHANICAL (Permit) OK except N's 31. A.C. Ducts; Insulation & Support as -Electric 19 WALon Sewer Connected -C/O to.Grade-HD Approval _ 32. Vent Fan; Exhaust above Insulation nergy Compliance Certificate -Other Certificates _ __33. Condensate Drain & Overflow; Size & Grade _ 34. Furnace -Vent; Access -Comb. Air -Return Air Vent -115V outlet 35. Attic Access & Platform if Furnace in Attic Card -BI -_ -- ----- Date _^ Card -BI Dated Card - l 0AjQ -BI Date Card -BI Date Date o+ and -BI Date Card -BI Date Card BI Date Card -BI Date Card -BI Date Date FRAMING(Plans) OK except q's 36. Sills; Proper Material & Anchors Comments at Final: _ 37. 38. 39. _Walls; Studs -Nailing, Spacing & Bracing -Plates -Sound Bearing Walls over Girders & Floor Nailing_ Draft Stop in Walls (rat proof) 40. Fire Stops; Furred Ceilings -Stairs -Chases -Tub 41. 42. 43. 44. Header & Beam -Size & Bearing Hangers -Post Caps -Anchors -Connectors Cing. Joist-Rftr. Ties-Purlin-Roof Brac.-Truss-Shthnq.-Rfng. Fireplace Ties or Type A Flue -Fireplace Throat 45. Attic Access: Size & Romex Protection -Draft Stop -Ins. Baffles 46. Bdrm. Windows or Exiling Doors -Sill Hgt. & Dimensions _ 47. Garage Fire Protection Framing (NOTE: An entry must be made each time youvisit jobsite) A r 11 PER 0. . t r PERMIT EXPIRES ` Tom Luper i OWNER {CONTR. owner 62-34=17 :LOCATION (A.P. ) E/S Sugar,Pine Dr., @ Madrone Way, lot -73, Ponderosa Pines Sub, Berry Creek r t t � J 7-'E> t i Temp. Power Pole Called PG&E it Temp. Elec. Serv. Called PG&E c Temp. Gas Serv.�/ Called PG&E JOB FINALED (Date) } (Signature) i• J�� " f A r 11 PER 0. . t r PERMIT EXPIRES ` Tom Luper i OWNER {CONTR. owner 62-34=17 :LOCATION (A.P. ) E/S Sugar,Pine Dr., @ Madrone Way, lot -73, Ponderosa Pines Sub, Berry Creek r t t � J 7-'E> t i Temp. Power Pole Called PG&E it Temp. Elec. Serv. Called PG&E c Temp. Gas Serv.�/ Called PG&E JOB FINALED (Date) } (Signature) i• J�� " COUNTY OF BUTTE — DEPARTMENT OF PUBLIC WORKS BUILDING INSPECTION RECORD BUILDING BUILDING (Cont'd) PLUMBING Setback 6-16-5-6c-- Firewall Soil Piping Forms Parapets 1st Floor Main Bldg. Restroom Finish 2nd Floor Footings 'P4A- F/AYA,Windows 3rd Floor StemwalI ;,JIY;X* X din g To out Slab Roof Sheathing Water Piping Piers - Roofing Sewer Garage Fdn. Vents Fixtures Footings Stemwa I I Garage Vents Insulation Water Htr. Heaters Slab Carport Footings Prov. for physically handica ed Conformance of ex. structure Appliances Gas PIPInq & Test Temp. Gas Slab Final Sanitation Patio FIREPLACE Final Footings Footing ELECTRICAL Masonry Walls Throat Rough •— Reinf. Steel Final Fixtures 7 Bond Beam FIRE SPRINKLERS Motors Framin —o5- - " Test Water Htr. Stucco Final Subpanels Mesh MECHANICAL Grd. Fault Prot. Scratch Heating Service Brown Cooling Temp. Pole Finish Ducts Under round Interior Lath I Ventilation Permanent Door Closer I Final Final MOBILEHOME UTILITIES Elec. Service Elec. Pedestal Water Piping Sewer Gas Piping =E ME INSTALLATIQN - - - - - - - - - - Support Elec. Continuity Water Piping Drainage Gas Piping DATE %alb REMARKS OR CORRECTIONS �/lna/1 Gat'_ C/C`r5 Fg>/Z— 295440--' F y— Vb6,1f— VJU (NOTE: An entry must be made on this form each time you visit the job site.) RESIDENTIAL ENERGY CONSERVATION STANDARDS CONSTRUCTION COMPLIANCE CERTIFICATE •THIS IS TO CERTIFY THAT ENERGY CONSERVATION REQUIREMENTS HAVE BEEN INSTALLED IN CONFORMANCE WITH CURRENT ENERGY CONSERVATION REGULATIONS AT East side of Sugar Pine Drive at Madrone Way (location) BUILDING PERMIT NO. 2622-80B,P,E,M A;P. NO. 62-34-17 THE FOLLOWING HAVE BEEN INSTALLED AS PER APPROVED.PLANS:- (Check each item or write N/A if not applicable) INSULAT ION : N Slab Edge Fdn. Walls Floors Walls Ceiling/Roof Ducts Circulating Pipes 11,4 APPROVED HEATER_ APPROVED WTR.HTR. GLAZING: Single Glazed /1/4 Special (Insulate CERT. & LABELED WDS. & SLIDING DRS. WEATHERSTRIPPED DRS. BACK DAMPERED FANS /¢Jl INTERMITTENT IGNITION DEVICES CERT. APPLIANCES //' I DECLARE THAT ALL REQUIRED ITEMS AS NOTED ABOVE HAVE BEEN INSTALLED IN ACCORDANCE WITH THE ENERGY CONSERVATION REQUIREMENTS AND AGREE TO THE COMPLETENESS OF THIS CERTIFICATE AS SUBMITTED. Insulation Applicator Name Signature of (please print) Insulation Applicator State Contractors License No. General Contractor Name -R46491- 1-4 SCho2wEAel.4 (please print) Signature of General Contractor Date 3 3 State Contractors License No. THIS CERTIFICATE MUST BE ON FILE WITH THE BUILDING DEPARTMENT PRIOR TO REQUESTING FINAL INSPECTION AND SHALL BE POSTED IN A CONSPICUOUS LOCATION WITHIN THE DWELLING. k1k 0 a -,TANDAIIDS CONSTROCTION (A)IMPLIANCE (:FKTTF1Q AIT J11J.') CERTIFY THAT ENFRGY CONSERVATION HQU1111-TIFITI'S IL,\V]:' BEEN IN CONSKIWA1 1.014 I%'EGk1I.AT'I()N"; (location) .1 I'T NO. A . P . THE. 'F0I',I.(AJ1TN(; 1IAVF _JSEFN I.N.STAI.11'1.-.D--X.�-111'k--ApPi ovr'riiiiiJ.s-- Whcck cacti item or writ: N/A -if not Ipplic.11,1e) NA VA Floors—__ 'J.1xill'uily, I.lipc,:.,,NA NA A1111i"kMA) GLA Z 114C : S i.: I j " I C. 'c' 1.1 z 0. d NA Special. ( 1`11:;ul telo A Crl(r. & LABELF.D WDS. & SLIDING DRS. NA WEATI I ERST RT I'll IM DRS. NA BACK DAHIT1-'I:D FANS__ NA 111TV Id -I 11' I'Vi 41- j(:Nl'l*l()N DI -Al ICE'S NA C F RT . A PPJ, I A 1: C i"S NA T. DF( I.AkF 1 -HAT ALL RE011TRED ITEMS A-) NOTED ABOVE HAVE It FI -:,N" "IT N. TA .1. IN M:C(iid1A1.1c1-: WIT11 TIIE FNER(A C(),H'jI-:RVATV)H PF(11.ITRI-TIENTS AND TO THE. 01' 'FlITS CI-:kTTFR:ATI-: AS SUB! I ITTE.D. Nama- ---.Hw I a 8;j1atj.Qn - Q -_-_Inc-- -71 ajn hr:111.1rion Applicator 7— State Contractors I.icV11sC No. 328407 Ccnc ra I 'Cont rac tor/(Mic r Wunc V L,3 r, (pIc.v;e print) S j i ',11.1tilre of G r. 11. C L) I I t r.1 c c o r owm c r Im t C %SO /.sLaLc 'coutractorn License No. Al 1. Ti; 7:'11 .f;!:'.T ON FTLF WITH THF, PI] TIJ) TN(', DITA WrTfFNT IT, ION, 'I Fli;1I, fON AND SHALL hF­P0:iTI-A) IN A CONST JUII()11,,: WCATION ' COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS PERMIT NO. 7 County Center Drive - Oroville, California 95965 - Telephone 916/534-4541 APPLICATION AND PERMIT Q p ASSESSOR P�.RCEL NUMBER ZO ING BUILDING PERMIT OWNER U � {/ ® /� � P/,1„r(/'[ TELEPHONE S0. FT. OCC. BUILDING VALUATION •��"V OWtaR�MAILING AD�ESS N !_ l lzssnovCONTRACTOR'S NIAME �7 TELEPHONE CONTRACTOR'S MAILING ADDRESS CONSTRUCTION LENDER —� UNKNOWN Fireplace ,00 Total Valuation $ ��, LENDER'S MAILING ADDRESS v Permit Fee g,Q $ ARCHITECT OR ENGINEER LICENSE NO. Plan Checking Fee Penalty $ �- ARCHITECT OR ENGINEER'S MAILING ADDRESS Permit fee % ��� $ BUILDING ADDRESS S St✓ r Cucv i PLUMBING PERMIT Filing Fee 3.00 ON �� Each Trap 2.00 1&,00 Repair drainage or vent piping 2.00 Water piping Z,O 0 LOT NO. 3 SU DIVISION NAME gyp. 7- i,,ad4,,.ca �ei SV� PARCEL MAP b-' Each qas water heater or vent 2.00 Gas piping system 1 - 5 outlets USE OF STRUCTURE SFD�5 Duplex❑ Mobilehome❑ Other SPECIFY Building sewer _rao Lawn sprinkler system 2.00 TYPE OF WORK New Addition ❑ Remodel ❑ Utilities ❑ Installation[] Other ❑ Describe work: Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 3.00 Main service 6001 OR LESS 100 AMP OR LESS 5.00 g�Q � Main service EA. ADO'L 100 AMP 2.50 � NEW CONST. D OR ADDNS. A ) 20 sq ft , CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): ❑ I am licensed under provisions of Chapt. 9, Div. 3 of the Business Professions Code and my license is in full force and effect. License No. Classification I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONSTR. ULTI-OUTLET 2,50 ea NON-RESID BRANCH CIRC ITS NEW CONSTR ( POWER APPARATUS &1 NON-RESID. SINGLE OUTLET CIR. Ex. Occup(OUTLETs OR FIXTURES 5 L@10 and FIXED APPLNS. OR Ex. Occup.(OUTLETS (RESID,) EA.) 2.00 Temporary service 10.00 Mobile Home Facilities 15.00 Misc. Wiri 6.25 Permit Fee , Contractor MECHANICAL PERMIT Filing Fee 3.00 WORKMEN'S COMPENSATION INSURANCE 1 declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. V I shall not employ any person in any manner so as to become subject iA to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Heating Cooling Hood ! 2.00 2,00 Ventilation Permit Fee $ s,d0 Contractor I certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the Countyot Butte to enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the County of Butte against all liabilities, judgments, costs, and expenses which may in any way accrue against s Countyingonsequence of the granting of this permit. "it. �� Date CJ Signature of Applicant - Owner [K Contractor ❑ Agent ❑ An OSHA permit is required for excavations over 5'0" deep and demolition or construct- ion of structures over 3 stories in height. Mobile Home Installation Fee $ Land Development Fee $ AO TOTAL PERMIT FEE $ oCCUP. GROUP X_ I TYPE OF CONST, -/_ A) PARCEL P11 HD SSUE This permit is hereby issued under sions of the Butte County Code and/or work indicated above for which DIREC OF PUBLIC By. PE EXPIRES Date the applicable provi-. resolutions to do fees have been paid. WORKS Date A- b' �0 Receipt No. 91R"2---4499 6tZ71- -- WNITE•D. P. W., YELLOW -ASSESSOR, PINK -INSPECTOR, • T COUNTY OF BUTTE — DEPARTMENT OF PUBLIC WORKS — BUILDING DIVISION 7 County Center Drive — 0roville, California 95965 — Telephone 534-4541 OWNER /CIW — i Proposed Building Use_ Permit fee based upon: PERMIT APPLICATION DATA SHEET os' Complete Contract Price Ot (expla' ) Building Inspector 72 ! At time of permit application, I was advised Issuance: 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Permit No. A. P.- No. g - 34--/7 DPW Valuation r Date -- 71 <^-ct�rCj following data must be submitted prior to permit processing and/or DATE RECEIVED APPROVED All items have been submitted................................................................... Plot plans in duplicate/triplicate............................................................... Complete plans in duplicate/triplicate................................................... Complete engineered plans and calcs..................................................... Plans with Energy Design Compliance Statement ............................ State Energy Forms No. .................... Statement of Intent for Non -Heated & AC Buildings ................... Feesof $.................................................. Letter of signature authorization............................................................. Sanitation approval from Health Dept.... Planning approval for Certificate of Workmen's Compensation Insurance ........................ C nn:`fr_actors�Li�nre In'i34'atYon (no., name style, classification) ............................... Improvements may be required. Contact Land Development Section of Dept. Public Works (see addressbelow)................................................................................................. Pre -inspection for required. Pre-inspec. request to p q bldg.inspector (date) �',e Other When you issue the permit, process as follows: Mail to owner Mail to contractor. Telephone and hold for pickup at office. Deliver w/inspection. Other r. 1�/ O!i r�Lf f k4 (r .i irr -4/4 14,0 C', , 6sE. Applicant �7 �, , Date Copy of plans sent Health Dept., Fire Dept., Other Date— During the plan checking process, the following data must be submitted prior to permit issuance: (For required items not checked above at time of application, circle item.) 1. Index permit for above Items No. 2. Additional items required: (Contractor, Designer, Owner) was advised of above required data by Plans approved by OTHER COPv/DPW Telephone Mail Other Date uaie Date r p 4a.. COUNTY OF BUTTE — DEPARTMENT OF PUBLIC WORKS — BUILDING DIVISION 7 County Center Drive — 0roville, California 95965 — Telephone 534-4541 OWNER /CIW — i Proposed Building Use_ Permit fee based upon: PERMIT APPLICATION DATA SHEET os' Complete Contract Price Ot (expla' ) Building Inspector 72 ! At time of permit application, I was advised Issuance: 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Permit No. A. P.- No. g - 34--/7 DPW Valuation r Date -- 71 <^-ct�rCj following data must be submitted prior to permit processing and/or DATE RECEIVED APPROVED All items have been submitted................................................................... Plot plans in duplicate/triplicate............................................................... Complete plans in duplicate/triplicate................................................... Complete engineered plans and calcs..................................................... Plans with Energy Design Compliance Statement ............................ State Energy Forms No. .................... Statement of Intent for Non -Heated & AC Buildings ................... Feesof $.................................................. Letter of signature authorization............................................................. Sanitation approval from Health Dept.... Planning approval for Certificate of Workmen's Compensation Insurance ........................ C nn:`fr_actors�Li�nre In'i34'atYon (no., name style, classification) ............................... Improvements may be required. Contact Land Development Section of Dept. Public Works (see addressbelow)................................................................................................. Pre -inspection for required. Pre-inspec. request to p q bldg.inspector (date) �',e Other When you issue the permit, process as follows: Mail to owner Mail to contractor. Telephone and hold for pickup at office. Deliver w/inspection. Other r. 1�/ O!i r�Lf f k4 (r .i irr -4/4 14,0 C', , 6sE. Applicant �7 �, , Date Copy of plans sent Health Dept., Fire Dept., Other Date— During the plan checking process, the following data must be submitted prior to permit issuance: (For required items not checked above at time of application, circle item.) 1. Index permit for above Items No. 2. Additional items required: (Contractor, Designer, Owner) was advised of above required data by Plans approved by OTHER COPv/DPW Telephone Mail Other Date uaie Date vc From C+v LruCetT: t.P•:x flt, ?Lh Sub,joct "?'itt'atlort k lasrJoze o. :, j�;�-�;� ... •+ ._ _ a. _ t e.�: 'c . J"^',# if t��7t3 � ;•Lh�3" _ _ -' `-' •-c _ _ _ _ __. ... .. _ rt � ._.. ata.an•'t 11r It CPT ...f '3 r Js��FT& OL COUNTY OF BUTTE —Department of Public Works 7 County.Center Drive, Oroville, CA. 95965 OWNER -BUILDER VERIFICATION Attention Property Owner: Phone: 916-534-4541 An "owner -builder" building permit has been applied for in your nameand bearing your signature. Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your build- ing 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 or no) 2. I (have/have not)__ c-pv.A 4AAAe-, signed an application for a building permit for the propowork. 3. I have contracted with the following person (firm) to provide the proposed construction: Name krl n)rP Address City Phone Contractors License 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, r Phone Contractors License No. 5. 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 Signed: Property Owner Social Security number Date NOTE:'This Owner -Builder Verification is sent to.you as'required by Sections 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. OROVILL.E, CALIFORNIA GENERAL CLAIM CLAIMANT; Tom Luper ADDRESS: General Delivery CITY & STATE: Berry Creek, CA. 95916 IMPORTANT: DATE OF CLAIM: June 9, 1980 SEE INSTRUCTIONS ON REVERSE SIDE SUBMIT CLAIM TO DEPARTMENT RECEIVING GOODS 'OR SERVICES DATE DESCRIPTION OF CLAIM (DESCRIBE FULLY TO AVOID DELAY) AMOUNT Overcharge on Building Permit #2622-80B,P,E,M - Receipt #38842 - AP 62-�=17� —� Building permit fee charged ----- $177.00 Should have been ________________ Refund due ---------------------------------- $45.00• Electrical permit fee charged --- $ 23.45 Should have been --------------- :SS Refund due --------------------------------- 6.60 TOTAL REFUND DUE ----------------------------$51.60 .$51, 60 TOTAL $51.60 I, the undersigned, declare under penalty of perjury that the services or articles claimed have been performed or delivered, and that this claim is true and correct as stated. Dated this.................. day of .... ^..1 Yl L,—.... 19 JL1 at Oro 17.1.1.1 fit,-..... Calif. .......IL.�"`... 1 c G... .............. l................................... Signature of laimant 1, the undersigned, hereby certify that, to the best of my knowledge, the services or articles specified above ha been performed or de- a livered and that there is a Budget Appropriation ❑ or Specific Beard Approval ❑ (Check one) for a .s. 9th June 80 Oroville Datedthis .................................... day nr ............................. 19....... at .............................. , Colif. ......... ...i....... .r s�. _.l .... ............. apartment head or Authorized Deput, Dept. Exp. Code............................................ Code ................................................PAYABLE FROM............................................................................................ FUND DO NOT WRITE BELOW THIS LINE _ AUDITOR'S USE ONLY VENDOR — CODE DEPT. 8 SUB.-- PROJ. SUB. OBJ_— CLAIM NO. INVOICE NO. INVOICE DATE DISC. GROSS AMOUNT ENCUMB. SUB -DIST. if fj jol 1 f if