HomeMy WebLinkAbout064-590-005. f
611
-590-005 PERMITN95-1809 _
)BSEN. D. Ivan
Hartnell Ct., Magalia
Single Family/gyp/9�
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.SIDENTIAL •
` �•
t` 064-590-005 PERMIT #95-1809'
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'JACOBSEN, D. Ivan -
6283 Hartnell Ct.!,
I
'New Single Family /
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EL eC BRIC
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JOB FINALED (Date) -.10-96
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Signature
4
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J=OK
O = Not OK t-
= Not Applicable
Not Ready MOBILE HOMES
=� -
Oates MOBILE HOME UTILITIES (Plans) OK except #'s
1. Zoning Requirements -Setbacks -Easements i
2. Soils; Special MH Support Sketch
3. Sewer; Location -Test -Fall -C/O Concrete
4. Water; Location -Test -Easement Needed (Sketch)
5. Electricity; Location-Clearences-Grnd-/ /Amp -Concrete?
6. Gas; Location -Test -Wrap: / /"L"ft. J
/ /"Nat. or/ /"L"ft./ /"LPG
7. Well Clearance & Disconnect
8. Utility Clearance
f
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 -Connector
7. Water and Sewer Connected -C/O to Grade -HD Approval
8. Gas and Electricity Tagged
9. Exits; Insp.-Sketch
10. Cert. of Occupancy
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
i
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; Griders and/or Joists -Decking -Bracing -Stairs -Rails
4. Wood Awn.; Posts-Beams-Rftrs.-Connectors
Shthg.-Rfg.-Bracing
5. Alum. Awn.; Columns -Connections -Splice -Decal -Enclosures
6. Carports; Windows -Doors
7. Electric
8. Frmg; Sils-Anchors-Studs-Rftrs-Trusses
9. Siding; Nailing -Veneer -Stucco -Mesh
10. Roof; Shthg-Rooting
11. Ext.; Steps -Doors -Landings
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, Distances-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 in Conduit
9. Health Department Approval
10. Plumb.; Cir. Test -Water Supply Test
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
12
a
r'
r
t
✓=OK
O = Not OK
Not Applicable
Not Ready RESIDENTIAL (;
=
Date t UND FLOOR (Plans) OK except #'s
-k loping -setbacks -Ease mentfood-Slope
21Y9., Main; Soils-Elec. G -/ " Ftg. Depth
Ft ., Garage; Soils-Steel-Elec. Grnd.-/ /" Ftg. Depth
Porches & Decks; Soils -Steel-/ /Ftg. Depth
temwalls, Main; Steel-Blockouts-Wrapped
Stemwalls, Garage; Steel- Bloc kouts-Wrapped
,-fia.-Hold Downs and Special Anchors
7. lab; Steel -Wrapped
P' rs-Fireplace Ftg.-Steel
D.W.V.; Fall -Fitting -Test -2 Way C/O -Sewer Test
0 F. Gas Pipe; Size -Anchors - yard gas piping: size -test
_rywater Pipe; Test -Anchor -Regulator -Service Test
12. Electric; Underground
13. Vienums & Ducts; Clearance -Material -Support -Ins.
rders-Sills-Anchor Bolts -Joists -Vents -Cripples
1 Access & Ventilation
16. Insulation �I
Date .2 Card B-1 Date Card B-1
Date L�jkt& Card B-1 S. -A Date Card B-1
Date PLUMBING (Permit),OK except ft's
16. Water Htr.: Vent -Access -Combustion Air -Baffle
Water Pipe: Test & Anchor -Nail Protection
-- - -- k_-1•9'D.W.V ; Test -Fittings & Anchor -Nail Protection - ---------------
--
19. Shower Pan; Test. First Floor -Tub Access --- - -
20. - Test Tub &--- Shower, - Second Floor -Tub Access
--------------------------------- -------------------
✓2't. Gas Pipe: Size & Anchors
-----------
- - -
----------
DateCard B_1 -- -Date - Card B-1
-----------
Date Card B-1 Date Card B-1
Date ELECTRICAL (Permit) OK except Ws
(/22. Fixture & Transformer Clearance -Ins. Protection
3. Elec. Receptacles Spacing -Lights & Switches at Doors
S' a Boxes & No. of Conductors -Stapled
----- - - - ------------------------------------------------------------
_ 25. om-- Installed Close to Edge of Studs & C.J.
------ • quip Ground made up w/Meth. Fastners-Bond Gas & Water ----
- - L�27. 2 Appliance Circuts in Kitchen & Conductor Size/GFI
----------------------------------------- --------------------------------
Subfeed
- ------------------------------
Subfeed Wire Size ga. Cu or AI-A.C. Wire Size ga.
Cu or At
-- ----------------------------------
29. Bang-e'-
ang-e Circ r r ga Cu or AI -Oven Circ. r / ga. Cu or Al.
L-;- Insulated Neutral ❑ Yes ❑ No
3 S ervice-Riser Conductors & Ground -Main Disconnect
------------ "---- ----------------------------------------------------
�Equip_Clearances Panels -Motors -Meth. Equip.
---------------------- ---------- ----------
L32. CI Closet Light -Shower Light -Spa Light
---------------- --------
Smoke Detector
- - - -Ca----- ---------------------------------------------------
--------------------------
-Date----- � rdB-
- ------Date-----------------CaCard----1
- - ---
Date Card B-1 Date Card B-1
Date MECHANICAL (Permit) OK except n's
34. A.C. Ducts Insulation & Support
3 Vent Fan: Exhaust above insulation
----- -- ------ -- - ------------------------ ----- ---- -----
Condensate Drain & Overflow: Size & Grade
-
Furnance-Vent: Access -Comb Air -Return Air Vent -115 outlet.
- - - - - - ------------------------ -- .
,10�9'D Attic Access & Platform if Furnance in Attic
------- ------ --- ------------------ ----------------
------------- -------------- ------------ ----------------- -- -
Date ` Card B_1 Date Card B-1
Date 1�'�Y�" Card B-1 ---. Date - --Card B-1-- --- ---_--
Date FRAMING (Plans) OK except ft's
_�Sil 'Proper Material & Anchors
�O. walls Studs -Nailing Spacing & Bracing -Plates -Sound - --
------ ------------ ---
41. Bearing Walls over Girders & Floor Nailing
2. Draft Stop in Walls (rat proof)
............. ---------------------------Fire Stops: Furred Ceilings -Stairs -Chases -Tub
-----------------------e_d_Ce-------------------------------------------
4Headers & Beam -Size & Bearing
•b
4
tingle & Duplex)
Date FRAMING (Continued)
Hangers -Post Caps -Anchors -Connectors
I g. Joist-Rftr. ties-Purlin-roof Bra c-Truss-Shthng.-Rfng.
replace Ties or Type A Flue -Fireplace Throat clearance
48 c Access; Size & Romex Protection -Draft Stop -Ins. Baffles
_ __Bdrm. Windows or Exiting Doors -Sill Hgt. & Dimensions
arage Fire Protection Framing
--- Pro erty Line Firewall & Openings
2. Ext. Doors -One 3 -Check Garage -3rd Story, 2 Exits
----- idth-Headroom-Rise-Run-Landing-Fire Protection
plywood on Roof Overhang -Attic Vents -Rafter Outriggers
ding -Nailing Veneer
o Mesh -Drip Screed -Fd. Vents-Underflr. Access
,5, azing Area -Glass Protection -Skylights -Plastic
58. ar Walls: Nailing -Bolts
Insulation -Walls -Ceilings
---------------- -
Infiltration -Walls -Windows
DatetWITCardCard B-1 G Date Card B-1
Date B-1 Date Card B-1
Date FINA (Plans) OK except ti's
E .Steps -Door &Sidelight Protection -Landings
------------- --- mookeke Detector
--
____________ 6- _. SDFurnace: Vents -Clearance -Comb. Air -Connector -
I 'Garage: Above Floor -Ducts -Meth. Protection
6 /gedroom Exiting
6_5_1. F.1 & Bath Fixtures & Tub Access -Spa
Elec. Trim & Subpanel: Breaker Sizes & Labels
------------------
67. Stairs & Rails
68. Fireplace or Stove: Clearances -Hearth
69. Elec. Outlets at Wood Panel: Int. & Ext.
-------------------
- - 70. Kit Fixt_& Appliance: Grnd_Air Gap -Cooking Clearance
71. Elec. Outlets & Receptacles at Kit. Counter
72.--Garage-Fire Door: Swing -Landing -Closer
- 73. A.C. Duct in Garage -Damper
74. Wtr. Htr.: Vents -Clearance -Comb. Air-Connector-P.R.V. .
In Garage: Above Floor -Meeh. Protection
75. Plb. Elec. & Mech_Equip. Listed for Location
76. Elec. Receptacles in Garage: (G.F.I.)-Romex Protection
--------------7,-.-Insulation-Foam-Looked in -Attic ❑ Yes
---------------------------- --
78. Guard Rails & Deck -Const ruct ion -Post Caps
79. Fdn Vents & Crawl Hole Door -Drainage & Wood -Earth
Clearance Looked under Floor ❑ Yes
80. Following instld.'Drive ❑ Yes ❑ No: Walks ❑ Yes O No:
Planters ❑ Yes ❑ No
81. Stucco: Brown -Finish -
82. A.C. Disconnect. Electrical, Plumbing
- --
83. Vents Above Roof: Plbg.-Appliance-Fireplace.-Clearance to
Openings
84. Water Well: Disconnect. Electrical, Plumbing
.... _ .. _85. Exterior Elec. Trim: G.F.I Receptacle -Underground - - -
86. Ventilation Throughout House
- - - - --------------------------- ----------------------------
87. Glass Protection
- - - -- - -- ------ --- ---------- ----------------------------
88. Corrections from Previous Inspections
--------- ----------------------------------------------
89. Gas Test -Meters Tagged; Gas -Electric
90. Water & Sewer Connected -C/O td Grade -HD Approval
Energy-------------------
-------------
Compliance Certificate -Other Certificates -
--- ---- � y - --
Date JP
Card B-1 p Date Card B-1
y ------------------------- --
Date Card -B-11 Date Card B-1
Date Card B-1 DateCard B-1
Comments at Final: 1 -
--- -- ��/o 4b ----1�---------- -
COUNTY OF BUTTE -DEPARTMENT OF DEVELOPMENT SERVICES -BUILDING DIVISION
V
7 County Center Drive - Oroville, California 95965 - Telephone (916) 538-754 PERMIT NO.
APPLICATION AND PERMIT S �� I
ASSESSOR PARCEL NUMBER
ZONING
R1
BUILDING PERMIT
•OWNER
TELEPHONE
SO, FT. OCC. BUILDING VALUATION
OWNERS MAILING ADDRESS
1566 R 84,564.00
920 M 16,560.00
CONTRACTOR'S NAME
_
T891-
1 N 44
405 C 5 , 265.00
4OE
182 C 2,366.00
CONTRACTORS MAILING ADDRESS
991-92,97
Fireplace A 1,500.00
CONSTRUCTION LENDER
UNKNOWN
Total Valuation $ 110, 255.00
LENDER'S MAILING ADDRESS
Filing Fee $
20,00
Permit Fee $ 678.00
ARCHITECT OR ENGINEER
LICENSE NO.
Plan Checking Fee $ 440.70
Energy Plan Checking Fee $ 23.00
ARCHITECT OR ENGINEER'S MAILING ADDRESS
Penalty $
BUILDING ADDRESS C
6283 HARTNELL �T MAGALIA
PERMITFEE $1161.70
PLUMBING PERMIT Filing Fee
20.00
Each Trap 11 7.00
77.00
LOT NO.
11
SUBDIVISION'S NAME
PARCEL MAP
38-17
Solar or heat pump water heater 1 23.00
USE OF STRUCTURE
SF X Duplex ❑ Mobilehome ❑ Other
SPECIFY
Water piping 15.00
15.00
Each gas water heater or vent 15.00
15.00
Gas piping system 1 - 5 outlets 15.00
15.00
Building sewer 15.00
15.00
TYPE OF WORK
New i7 Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other ❑
Describe Work: 3 BR
-
Mobile Home I S I GI W 1 920.00
PERMITFEE S 157.00
Contractor
ELECTRICAL PERMIT Filina Fee
20.'00
Main Service ( 20000AA OR LEOR LESSSS ) 23.00
2
23.00
Main Service ( 200A TO 1000A ) 46.00
LICENSED CONTRACTOR'S 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 the Business and Professions Code,
and my license is in full force and effect.
License Class Lic. No.
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the Contractors License
Law for the following reason:
❑ 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.
I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project.
❑ 1 am exempt under Sec. Business and Professions Code for this
reason
NEW CONST. DWELLING OCCUP. so.
OR ( 8 ACC. ) 3.SQ FT.
p
54.81
CNS.
NEW CONST. MULTI-OUUTLETLE T
NON-RESID. ( BRANCH CIRCUITS ) 97.50
( POWER SINGLE APPARATOUTLET SUS )
8 R.
Ex. Occup. (OUTLET OR FIXTURES) 20 Q 1.00
BAL .00
EX. Occup, OUTLETS PESID.OEA
( ) 5.00
Temporary Service 23.00
23.00
Mobile Home Facilities 20.00
Misc. Wiring 23.00
PERMITFEE $ 120.81
Contractor
WORKERS' COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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.
❑ 1 have and will maintain workers' compensation insurance, as required by Section
3700 of the Labor Code, for the performance of work for which this permit is issued.
My workers' compensation insurance carrier and policy number are:
Carrier
MECHANICAL PERMIT Filing Fee
20.00
Heating
0
Cooling
15.00
Hood 6.50
6.50
Ventilation
4.50
PERMITFEE $
Contractor
Policy Number
(The above sections need not be completed if the permit is for work of a valuation
of one hundred dollars ($100) or less.)
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 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 ith those provisions.
�q
X /t/ _ Date _J& 1- 7/915 _
Signature of Applica - 0( Owner ❑ Contractor ❑ Agent
An OSHA permit is required for excavations over 60" deep and demolition or construction
of structures over 3 stories in height.
Mobile Home Installation Fee $
Energy Inspection Fee $
46.00
Occ
CONST. TV PE
TOTAL FEE $1546.51
I
HAZ.
_
D. FEES
IMP
X
FLOOD
X
CDF
X
P CEL PID �jP
n ]C
ISSUE
This permit is hereby issued under the applicable provisions
of the Butte County Code and/or Resolutions to do
indicated above for which fees have been paid.
By Date
PERMITEXPIRESON d )
(Date)
work
Z
FReceiptNo. 180573 - 1524.19 185224 - 17.32 ADD.
ITE-D.D.S.-B.D. CANARY -ASSESSOR PINK -INSPECTOR GOLDENROD -APPLICANT
COUNTY OF BUTTE - DEPARTMENT OF DEVELOPMENT SERVICES - BUILDING DIVISION
7 County Center Drive - Oroville, California 95965 - Telephone (916) 538-7541 PERMIT NO.
�- APPLICATION AND PERMIT
ASSESSOR PARCEL NUMBERy^' _ O
ZONI
BUILDING PERMIT
•OWNER I V=TA
TELEPHONE
SO. FT. OCC. BUILDING VALUATION
OWNERS MAILING ADDRESS
2,3 kA1Z:rA)EL(_ 01
5
42 0 /
CONTRACTOR'S NAME
T7
'j//412
CONTRACTORS MAILING ADDRESS
Fireplace �C 00
CONSTRUCTION LENDER
UNWINC
Total Valuation $
LENDER'S MAILING ADDRESS
Filing Fee
$
20.00
Permit Fee $
�Q
ARCHITECT OR ENGINEER
LICENSE NO.
Plan Checking Fee D
$
Energy Plan Checking Fee
$ �3. pa
ARCHITECT OR ENGINEERS MAILING ADDRESS
'
Penalty
$
BUILDING ADDRESS
(Zr �'�- C%
PERMITFEE
$
_
A7464 u
PLUMBING PERMIT
Filing Fee
20.00
Each Trap 11 7.00
-0o
IT SUBDIVISION'S NAME PA 5 AP
Tiq IJJ'i
Solar or heat pump water heater
23.00
USE OF STRUCTURE1'.—,00Each
SF �' Duplex ❑ Mobilehome ❑ Other
SPECIFY
Water piping
15.00
�,c0
gas -water heater or vent 15.00
5- W
Gas piping system t - 5 outlets 15.00
15,(Z
Building sewer
15.00
TYPE OF WORK
New,k Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other ❑
Describe Work: 3 I3 �� �.Oa(►M
Mobile Home S I G W
920.00
1.
PERMITFEE s 7_ O
Contractor
ELECTRICAL PERMIT Filino Fee 20:00
'
Main Service a00V OR LESS
( 200A OR LESS )
23.00
23,00
Main Service ( 200A To I000A )
46.00
LICENSED CONTRACTOR'S 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 the Business and Professions Code,
and my license is in full force and effect.
License Class I No.
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the Contractors License
Law for the following reason:
❑ 1, 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.
❑ 1, as owner of the property, am exclusively contracting with licensed contractors
to construct the project.
❑ 1 am exempt under Sec. Business and Professions Code for this
reason
NEW CONST. DWELLING OCCUP.
DR ADDNS. ( a ACC. BLDS. )
SO.
3.5¢ FT.
NEW CONST. MULTI.OUTLET
NON-RESID. ( BRANCH CIRCUITS ) 97.50
POWER APPARATUS )
( 8 NGLE OUTLET CIR.
Ex. Occup. (OUTLET OR FUTURES ) 20 Q I.00
SAL SO
Ex. Occup. OUTLETS RES D.)OEA
( ) 5.00
Temporary Service 23.00
23,Q,
Mobile Home Facilities 20.00
Misc. Wiring 23.00
PERMITFEE $ I_J
I
Contractor
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 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 required by Section
3700 of the Labor Code, for the performance of work for which this permit is issued.
My workers' compensation insurance carrier and policy number are:
Carrier
MECHANICAL PERMIT
Filing
g Fee
20.00
Heating
15 00
Cooling
ISS QJ
Hood 6.50
,Sp
Ventilation 1111156
q-5,0
PERMITFEE $
-
Contractor
Policy Number
(The above sections need not be completed if the permit is for work of a valuation
of one hundred dollars ($100) or less.)
❑ 1 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 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 Date
Signature of Applicant - ❑ Owner ❑ Contractor ❑ Agent
An OSHA permit is required for excavations over 60" deep and demolition or construction
of structures over 3 stories in h ijghhtt. DP
Mobile Home Installation Fee $
Energy Inspection Fee$ QO
co T .
TOTAL.FE $ _
HA Z. 0. FEES P FL O COF ARC . PO SS UE
P
This permit is hereby issued under me
of the Butte County Code and/or
indicated above for which fees have
By
PERMITEXPIRESON
applicable provisions
Resolutions to do
been Yd
[ iVj
Date
(Date)
work
J
i
/
Receipt No. 8 d57 I c� o ! �� a
WHITE-O.O.S.-B.D. CANARY -ASSESSOR P NSPECTOR GOLDENROD -APPLICANT
^
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^
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U
I�/T
� �-.� . y_��!s .. .app •.�r.�-`;a • _ � "i ��F
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-
COUNTY OF BUTTE
'#
BUILDING,DIVISION
t4 .
DEPARTMENT OFjDEVELOPMENT SERVICES
1469 Humboldt Ro a; Chico, CA --(916) 891-2751`
=4...7 County Center Drive; Oroville, CA- (916) 53$-7541
3
747 Elliott Road,,Paradise, CA - (916)872-6307
t
CORR9CTIO�N NOTICE
!
OWNER 1 e
PERMIT NO.
A routine inspection indicates that the folld'wing violations of Butte County Ordinances exist at r
_
the above address and should be corrected. Please notify this office whencorrection of work
is completed. I you have any questions pertaining to this matter, or need additional explanation,
please'co ct this office immediately.
'1 O. 1 r`
'j SOMA 1
,. .� -�. 1.•.-: ;., s ice'" .", �
ACT
r •'S`
s
1
�f
Date
REV 10/92.
Inspector ��
COUNTY OF BUTTE
BUILDING DIVISION
DEPARTMW OF DEVELOPMENT SERVICES
1469 Humboldt'Road,%%hico, CA - (916) 891-2751
7 County Center Drive; 0' bviIle, CA - (916) 538-7541
747 Elliott Road, Paradise, CA - (916) 872-6307
CORRECTION NOTICE
OWNER PERMIT NO.
A routine inspection indicates that the following violations of Butte County Ordinances exist at
the above address and should be corrected. Please notify this office when correction of work
is completed If you have any questions pertaining to this matter, or -need additional explanation,
please 5Pftact this office immediately.
I
'Ou Q W
G /N
Date Inspector
REV 10/92
y
TO: J ��Building Department
FROM: Environmental Health
SUBJECT: Sanitation Clearance
i
F.H. USE ONLYv
Hol Phm Auached GG S
Flom Man Auachrd `C S� }
senC
t �o B.U. �3' 1 S` I
6e�(-.5-90- 005
-
'Owner / Location AP#
Plan Approved for: Sewage Disposal ✓ Water Supply: Public Private Well
Clearance for �_ bedroom AAAhome. Other
Hold final for: -
Final•clearance O.K. for:6
NOTE:
Environmental alth Specialist
8/92
Acy 1, /.3 q5—
—
D to
� � f
COUNTYOF BUTTE - DEPARTMENTOF DE,VELOPMENTSERVICES -BUILDING DIVISION
7 COUNTY CENTER DRIVE - OROVILLE, CALIFORNIA 95965 -TELEPHONE (916) 538-7541
OWNER
Proposed Building Use
PERMIT APPLICATION DATA SHEET
VAN -TA Cr) ASEd A. P. No. -045
L41 C L iW C, Building Inspector Gi D 8 a14< Date 7-27� IFS
At time of permit application, I was advised the following data must be submitted prior to permit processing and/or issuance:
DATE RECENED BY
1. All items have been submitted . .............. ..... ...........
2. Plot plans, 3/4 sets, _signed by preoarer of plans_. J. .t T /} D ro.,/�� ..
3. Complete plans, 3/4 sets, signed b� prc; arer of„plans... �>:.lizbU fLE.)s ...... .
4. Engineered plans and calcs, 3/4 sets, with wet signature on plans . .............
5. Hazardous Material Form . ........................................... .
6. Energy Design Compliance and supporting documentation . ..................
7. Statement of Intent for Non -Heated and A/C Buildings . ..................... .
8. Engineered truss details and layout in duplicate (required prior to plan check). ... .
9. Mobilehome d to an manufacturer' irystallation instructions, 2 sets. ...........
10. Fees of $ r 7..�v.....................................
11. Impact fees as shown on a ached schedule. . .
.. .... .......
0��:
California Department of Forestry plan approva feesrclv...i�
13. Flood elevation letter (100 year flood) by Californi gineer. ................ .
14. Sanitation and plot plan approval C N i C o Health Department . ............ 8�
15. City of Chico plumbing permit . .........................................
16. Plot plan and business license approval from City of Biggs/Gridley. .............
17. Planning approval for (A) Use: (B) Parking: . .........
18. Contact Land Development about (A) Improvements (B) Drainage. .......... .
19. Driveway permit (construction approval required prior to occupancy). .... . .
Preanspedion requ�
20. Pre -inspection for required. . to Building inspector (Date)
21. Contractor's license information. (No., Name Style, Classification) . ..............
22. Certificate of Workmans Compensation Insurance. .........
29 Owner -Builder Verification Given to owner.........
Mail to owner
4. Recorded copy of Agricultural Acknowledgement Statement . .................. is
Letter of signature authorization . ........................................
26. Copy of recorded deed of parcel creation and 60 right of way to a public road. .....
27. Letter of intent on building use . .........................................
28. Mobilehome utility clearance . ..........................................
29. Documentation of legal access . ..................... :.................. `
30. Documentation of 50% subdivision developed or (A) Road improvements completed
and (B) Parcel meets zoning area and frontage requirements . ...............
31. Existing violations/expired permits . ......................................
32.
Plan check list ......................................................
4
34.
When you issue the permit, process as follows: V Mail to owner. Mail to contractor.
T Telephone 80 and hold for piickup a office. Deliver with inspector.
Other 'k-159-544
Parcel Creation
Acreage Applicant Date
Copy of Haz-Mat form sent Health Dept. Fire Dept. Air Pollution Date
Copy of plans sent Health Dept. Fire Dept. Other Date By
The following data must be submitted prior
1. Index permit for above items No.
2. Additional items required:
issuance; (Circle
not
Contractor, designe , own- , was advised of above required data byJ� phone _ mail Counter b*Z-3-Date gjf�K
Contractor, designe , ner, was advised of above required data by _ phone _ mail o nter by _ Date
Plans checked by Date - Plans approved by Date
Sets of plans on hold in File cabinet AP folder
Copy - Department of Public Works
f 1
COUNTY OF BUTTE - DEPARII11EMT OF DEVELOPMENT SERVICES - BUILDING DIVISION
7 COUNTY CENTER DRIVE, OROVILLE CA 95965 - TELEPHONE (916)'538-7541
OWNER ' r ' "d1AV JAcobsEn/ A.P. #_ 06y_.5017-00
PROPOSED BUILDING USE S F ' W a- (IVG DATE -7-27-1
REC. # DATE REC
A 1. SCHOOL DISTRICT FEES
(paid at District•Office).........................
2. SHERIFF FEES
(paid at Building Department)
Residential ..... x =$ 05 73 7 27-5.r
unit amt.
Commercial (sqft) x =$
sq. ft. amt-.
3. URBAN AREA FEES
(paid at Building Department)
Residential (per unit) x =$
—F—units amt.
Commercial (per sq.ft) x =$
sq.ft. amt.
4. RECREATION DISTRICT FEES
(paid at District Office) .........................
5. DRAINAGE DISTRICT FEES
(Contact Land Development Division) ..............
6. SRA FIRE INSPECTION AND PLAN CHECK = $89.00 ...... BO,
(paid at Building Department)
7. OTHER
8. OTHER
At time of. permit application, I was advised the above fees are required to be paid
prior to issuance of the permit.
APPLICANT DATE - a 7 23�
8/91
RESIDENTIAL PLAN CHECKING GUIDE
MISCELLANEOUS ITEMS TO LOOK OUT FOR
Stairway details: landings, rise and run, head clearance, handrails
. (Sec. 3306).
Guardrail details (Sec. 1711 & 33O6(j).
Brick or stone veneer (Chapter 30).
Exterior plaster - weep screeds (Sec. 4706).
Proper roof pitch for roof,convering'(Chapter 32).
Roof covering type - (fire hazard)..
Foam insulation - protection.
.36" halls and stairways.
Living area over garage = complete 1 -hour separation required on garage side
including supporting walls and posts, etc.
. Two exits on three-story dwellings (sec. 3303 & see Mezannines - 1716).
. Attic access and ventilation (Sec. 3205).
•nderfloor access and ventilation (Sec. 2516).
. Combustion air for fuel burning appliances - L.P.G. requirements.
• Noise requirements on duplexes.
Energy design.
�'Flashing at all exterior openings.
CDF responsible area requirements.
C_%
7 ��
0
RESIDENTIAL PLAN CHECKING GUIDE 8/91
(S.F., DUPLEX & MISC. ONLY)
Bldg. Permit #
OWNER A.P. # v5
GEPlan Checker -/O
NERAL
4- Zoning requirements: (sideyards and number of permitted living units).
Valuation.
Plans signed by designer.
f� Proper description of work on application.
Existing violations on property.
Items on data sheet. (W.C., fees, Health, Developer Fees, License law, etc).
Recorded notice of violation.
PLOT PLAN
• Complete parcel size and dimensions.
. Setbacks, sideyards, easements, etc.
Other buildings or structures.
rading, fills, drainage.
Flood hazard.
Special conditions on creation map,
ustible, and foundations).
FAU & FAS road setback.
(noise, CDF, fire sprinklers, non -comb -
Building or utilities across lot lines (Record form).
FLOOR PLAN
[• Complete to scale plan with dimensions.
• Required windows for light and ventilation (Sec. 1205).
• Required windows for second exit (Sec. 1204).
• Skylights (Chapter 34 & Sec. 5207).
• Human impact glass (Sec. 5406).
• Required room sizes, ceiling heights (Sec. 1207).
• GFCIs in baths, garage, kitchen, and exterior outlets (Article 210-8).
• Light fixtures, switches, receptacles, and exterior receptacles for main-
tenance of mechanical equipment.
Locations of water heater, heating and cooling equipment, other electrical
or gas equipment.
.F_ Garage firewall, door size, and closer (Sec. 503(d)(3)).
1 - 3'0" exterior exit door (sec. 3304 (f).
-'Fireplace and wood stove location, alcoves, and clearance.
1�.,Smoke detectors (Sec. 1210).
WPlumbing fixtures, water closet clearances and -shower size.
STRUCTURAL DETAILS,
Standard bracing or engineered design (Table 25V)
Unusual shape, size, or split level house requiring lateral design.
Clerestory requiring balloon framing and/or engineering.
Three story building requiring engineered calculations and plans.
Foundation plan complete enough to construct building.
oor construction details complete enough to construct building.
Elevations and wall construction details complete enough to construct
Roof construction details complete enough to construct building.
T Fireplace construction details and calcs if necessary.
ai-Rafter ties or bearing ridge beam.
Garage door or porch header sizes.
Stud heights.
Adobe soils - special foundation design.
4:` Retaining walls requiring design.
Special Inspection required.
building
And when recorded mail to:
Building Division
#7 County Center Drive
Oroville, Ca. 95965
95-0256271. 'Rec' Fee
• I Check
:,F a
Recorded,,,,,,
Officiai Records 1,
County. of
Butte 1"
4 `Candace J. , Grubb_e I '
Recorder' I '
8:246m 2 -Aug -95I' PUBL
-6.00
6. 00
r.
XX 1 `
AGRICULTURAL STATEMENT OF ACKNOWLEDGMENT -
FOR RESIDENTIAL DEVELOPMENT
Section 26-8 of the Butte County Code requires this acknowledgment to be recorded prior to issuance of a building permit. The
property described herein is adjacent to land or included within an area zoned for agricultural purposes,and residents of this
property may be subject to inconveniences or discomfort from the use of !agricultural chemicals,' including, but not limited to
herbicides, pesticides, and' fertilizers;, and from the pursuit of agricultural _operations including, but not limited to cultivation,
plowing, spraying, pruning, and harvesting which occasionally generate dust; smoke; noise, and odor. Butte County has established
` agricultural purposes and residents within said zones and'on adjacent property should be prepared to accept such inconvenience or
discomfort from normal, necessary farm operations.
All that real property situate in the County of Butte, State of California, described as follows:
AOT )/7 A,5 51-101uv oil! 'THAT C Z`R7-{iN MAP- A NjYTL4p /'q R,9 a/SL= /M[� N, ,,7 � [/
p
f1A J_= ;D 1/V rN'L oF/ iC e F ZN4 c°ocl �CiD)/ RL cm,Q
1 S a/= w/RPSJ 475..�Iwo /qo
06ti>S70 —
NJRTt/ L -AS7- Co)eaL;2 01- CRL=sTon/ H4 le
Date: /76� PROPERTY O RS:
State of California )
County of ,3zv%� )
On ,'7'01/—/S before me, /%%
personally appeared �'--�'c. ACO b Aq- G ly ersonally
known to me (or proved to me on the basis of satisfactory evidence) to be the persons) whose name(s) is/are subscribed to the
within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and
that by his/her/their signatures) on the instrument, the person(s) or the entity upon behalf of which the person(s) acted,
executed the instrument.
WITNESS my hand and official seal. 91-1
Maurine R. Johnson�
Comm. #987464
\ O AW PUBLIC CALIFORNIA
BUTTE COUNTY 0
Signature Comm. E>tpine8 March 14, 1997
A.P.#
END OF DOCUMENT
NOTE TO RECORDER: DO NOT RECORD THIS SIDE A.A.- 1
..
..
AGRICULTURAL STATEMENT OF AKNOVLEDEEN'F
Instructions for recording Agricultural Statement of Acknowledgement:
1. Insert the legal description'of the property in the space.provided on the other side of this
form. The legal description is the narrative description of the property - which will be on
your deed. If you'. don't have access to the deed, the Recorders Office can provide this
information. ( The description may be handwritten or typed in the space provided or attached
on a separate sheet if more space is required).
2. Property owners must sign in the presence of a Notary Public and have the form notarized.
3. Make a copy of the form and then take the original and copy to the Recorder's Office at 25
County Center Drive, Oroville (the Administr4tion Center building). The Recorder will
record both the original and copy. They will keep the original and return the copy to you.
Just bring the copy back to the Building Division at 7 County Center Drive.
RECORDER'S FEES: $6.00 - 1st. Page
$3.00 - Each Additional Page
RECORDER'S OFFICE HOURS: 9:00a.m. - 3:00p.m. (Monday - Thursday).
AA
�'g_. �iSZuC:.:`i7i�2� .M3St:� s,. h.> ' •::r ,..
OVER
:Al[aY,N++•y� ri.as.7�SitC{fniciur'r'iu17°iSTMiii�4t:.yx?.�wT�ai�'R�.18,+�dytjarny,jsyv�pirb '�" ya�i .. rM �++xr ".•
���" i n• r3 iK1r.:t:Hwr•"
t
BUTTE COUNTY SCHOOLS IMPACT FEE CERTIFICATION FORM
(One Form Per Building)
School District PA KA r5 9- Building Department No.
A.P. Number Jurisdiction:' City County j
Property Owner b, I V AIV J -A C n'8 5 E /V
Property Location/Address 628-3 A JZ rN E LL C T',,
Subdivison Lot No.
Residential Development Sq. Footage /S
No. of Living MHI Addition (Group R)
Units
Commercial/Industrial, Sq. Footage
New Addition (Including Exterior
Roofed Areas)
t
7 -e7 -19S
Building Department Representative Date
(Floor Plans reviewed by School District Personnel)
Diso.rluiL-�-d✓i
hoot District certifies that(1
(Applic t)
(Street Address) ,; (Phone;Number)
(City) (State) (Zip ode
has complied with the requirements of Resolution No, by payment of $
representing p square feet. As 2926 $
FULL MITIGATION $
School Distriot Representative Date `
Paid by Check # Remarks:
Bank Number
Paid by Cash
If, subsequent to the School District Representative signing this Butte County Schools Impact Fee
Certification Form, the School District is notified by the applicable Local Planning Agency that this project
is being reviewed under the California Environmental Quality Act (CEQA), this project may be subject to
additional school fees to fullv mitigate its imaact on the school district's schools.
White (applicant), Yellow (building department), Pink (school district) teeiormmkl (11/94)dmm
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MANDATORY MEASURES CHECKLIST: RESIDENTIAL Page 1 ii, MF -1R
Project Title..........
MASTER PLAN
Date........ 01/01/93
Project Address........
MASTER PLAN
------------ ---------
CHICO, CA.
Documentation Author...
BOB METZGER 865-9688
; Building Permit # ;
Company ................
BOB METZGER 0 D S
i
Telephone ..............
865-9688 or 342-9688
; Plan Check / Date ;
Compliance Method......
MICROPAS4 by Enercomp, Inc.
; Field Check/ Date ;
Climate Zone...........
11
---------------------
MICROPAS4 v4.01
File-. Wth-CTZ11S92
Program -FORM MF -1R
User#-MP1000
User -BOB METZGER 0 D S Run-
--------------------------------------------------------------------------�----
Lowrise residential buildings subject to the Standards must contain these
measures regardless of the compliance approach used. Items marked with an
asterisk (*) may be superseded by more stringent compliance requirements listed
on the Certificate of Compliance. When this checklist is incorporated into the
permit documents, the features noted shall be considered by all parties as
binding minimum component performance specifications for the mandatory measures
whether they are shown elsewhere 'in the documents or .on this checklist-10jIly.
BUILDING ENVELOPE MEASURES Ih�-,tel
--------------------------to
_a
esign- nforce-
. er ment
*150(a): Minimum R-19 ceiling insulation. A
150(b): Loose fill insulation manufacturers labeled R -Value.
*150(c): Minimum R-13 wall insulation in framed walls
(does not apply to exterior mass walls).
*150(d): Minimum R-13 raised floor insulation in framed floors;
minimum R-8 in concrete raised floors.
150(i): Slab edge insulation - water absorption rate no greater
than 0.3%, water vapor transmission rate no greater than 2.0
perm/inch.
118: Insulation specified or installed meets CEC quality
standards. Indicate type and form. E")
116-17: Fenestration Products, Exterior Doors and Infiltration/
exfiltration controls
a. Doors and windows between conditioned and unconditioned
spaces designed to limit air leakage.
b. Manufactured fenestration products have label with
certified U -value, and infiltration certification.
c. Exterior doors and windows weatherstripped; all joints r ��
and penetrations caulked and sealed.
150(8): Vapor barriers mandatory in Climate Zones 14 and 16
only.
150(f): Special infiltration barrier installed to comply with
Sec. 151 meets CEC quality standards.
150(e): Installation of Fireplaces, Decorative Gas Appliances
and gas logs
1. Masonry and factory -built. fireplaces have:
a. Closeable metal or glass door
b. Outside air intake with damper and control
c. Flue damper and control
1 2. No continuous burning gas pilots allowed. E to L y�
J. ._ -
��02 v•�'- -Z-
110-13:
110-13: HVAC equipment, water beaters, showerheaas ana faucets „
certified by the CEC.
150(i): Setback thermostat on all applicable heating systems. L -_l1
1500): Pipe and Tank insulation
1. Indirect hot water tanks (e.g., unfired storage tanks or
backup solar hot water tanks) have insulation blanket (R-12
or greater) or combined interior/exterior insulation (R-16
or greater).
2. First 5 feet of pipes closest to water heater tank, non -
recirculating systems, insulated (R-4 or greater).
3. All buried or exposed piping insulated in recirculating
sections of hot water system.
4. Cooling system piping below 55 degrees insulated.
5. Piping insulated between heating source and indirect
hot water tank. .-�
*150(m): Ducts and Fans
1. Ducts constructed, installed and sealed to comply with UMC
sections 1002 and 1004; ducts insulated to a minimum
installed value of R-4.2 or ducts enclosed entirely within
conditioned space.
2. Exhaust fan systems have backdraft or automatic dampers.
3. Gravity ventilating systems serving conditioned space have
either automatic or readily accessible, manually
operated dampers.
114: Pool and Spa Heating Systems and Equipment
1. System is certified with 78% thermal efficiency, on-off
switch, weatherproof operating instructions, no electric
resistance heating and no pilot light.
2. System installed with:
a. At least 36 inches pipe between filter and heater for
future solar heating.
b. Cover for outdoor pools or outdoor spa.
3. Pool system has directional inlets and a circulation
pump time switch.
115: Gas-fired central furnace, pool heater, spa heater or
household cooking appliance have no continuously burning
pilot light (Exception: Non -electrical cooking appliance
with pilot < 150 Btu/hr.).
LIGHTING MEASURES
-----------------
Design- Enforce-
er went
150(k): 40 lumens/watt or greater for general lighting in
kitchens and rooms with water closets; and recessed ceiling
fixtures. IC (insulation cover) approved.
^_ Be aware that glazing units (including doors with
:glass)---must.have permanent NFRC labels. Glazing labels will be
`*checked against the Title 24 calculations at the time of framing t
inspection. If the installed U -value is of a lesser value, the Title 4
24 calculations must be redone, and appropriate changes made to the
structure (e.g., this may include additional insulation, addition of
screening devices, reduction of window sizes, etc.).
Note that an Installation Certification Form CF -611 is required to be
"posted at the residence proper to the issuance of a Certificate of
%,_Occupancy. This is in addition to the Insulation Certificate.
IF APPLIES GENERAL NOTES SHEET E
1. ALL PENETRATIONS THRU THE BUILDING ENVELOPE (CLG. WALLS AND
FLOORS)Tb6E CAULKED, SEALED OR WEATHER STRIPPED. SHIM SPACES AROUND
EXTERIOR DOORS OF THE BUILDING ENVELOPE TO BE INSULATED.
2. ALL EXTERIOR PANELS EDGES TO BE CAULKED.
3. ANY ACCESSESS TO ATTIC SPACE OR CRAWL SPACE FROM CONDITIONED SPACE
TO BE FULLY WEATHER STRIPPED.
4. EXHAUST FANS TO HAVE BACKDRAFT DAMPERS.
5. FIRE PLACES TO HAVE. a) O.S. COMBUSTABLE AIR TO F.P. BOX W/ MIN.
DUCT CROSS-SECTIONAL AREA OF 6 SO. INCHES -b) DAMPERS TO ' 'DUCT
ACCESSABLE FROM INSIDE F.P. AREA c) FLUE DAMPER- TIGHT -FITTING 8
READILY ACCESSABLE d) TIGHT -FITTING F.P. DOORS OR HEAT CIRCULATING
DEVICE.
6. A/C DUCTS TO BE INSTALLED PER MO.A U.M.C. 8 INSULATED 0" INSUL.-
GAS EQUIP.) 8 (2" INSUL.-HEATPUMP EQUIP.) 15# DENSITY TYP.
7. MAIN LIGHTING SOURCE IN ALL BATHS 8 KITCHEN TO BE FLOURESCENT OF
4.0 LUMENS/WATTS OR GRATER.
8. FAUCETS 8 SHOWER HEADS TO BE WATER SAVING TYPE 8 CERTIFIED BY C.E.C.
9. W.H. TO HAVE.
a) f-6" H I GHT PLATFORM.
b) . VENT T HRU ROOF.
c) ADEQUATED CONBUSTABLE AIR VENTING. _
d) R-4 INSULATION 5'-0- TO 8 FROM UNCOND. SPACE.
e) R-12 INSULATION WRAPPING.
f) R-4 INSULATION ON CIRCULATING SYSTEM.
g) CERTIFIED BY C.E.C.
10. GAS COOKING APPLIANCES NOT TO HAVE CONTINUOUS BURNING PILOT LIGHT.
11. A/C UNIT TO HAVE
a) SIZED 8 CERTIFIED BY C.E.C.
b) SET -BACK THERMOSTATS.
12. INSULATION INSTALLER TO BE CERTIFIED BY STATE 8 LOOSE FILL INSULAT-
ION TO HAVE MANUFRS. LABLED R -VALUE
13 BUILDER TO SUPPLY TO OWNER ALL INFO. PERTAINING TO THE OPERATION
OR TREATMENT OF ALL APPLIANCES 8 DEVICES RELATED TO ENERGY OR
WATER USE.
14. ALL WDOS. @ CONDITIONED SPACED DUAL -PANE. DOORS 8 WDOS. TO BE FUL-
LY . 1 WEATHER STRIPPED.
15. CAULK BETWEEN BOTTOM PLATE AND CONC. FLOOR.
16. PROVIDE INSULATION BAFFLES @ EAVE BLOCK VENTS.
17. USE ELECT. OUTLET GASKETS @ O.S. WALLS.
18 WATER HEATER TO'HAVE P -T VALVE WITH DISCHARGE TO OUT SIDE.
19. REF. FRZRS. FLUR. LAMP BALLAST TO BE CERTIFIED BY C.E.C. CON TRACT-
OR -OWNER TO SUPPLY MAKE AND MODEL.
� � S
LAND DEVELOPMENT - BUILDING PERMIT CLEARANCE Building Permit No. 95 — /9(
0 X I(L-w Z -6o 1,4
NAME4:seo,RS NUMBER:( / --,sqD
PRINT LAST NAME FIRST
COUNTY ZONING \ /
DESIGNATION: F ( FLOOD ZONE: JC FLOOD MAP: 15o C3
APPROVED: _
DATE OF CREATION:
CONDITIONALLY APPROVED: RESOLVE PROBLEMS PRIOR TO APPROVAL:
PARCEL CREATION BY DEEDS
DEED REFERENCE:
LEGAL ACCESS PROVIDED: YES NO LEGAL ACCESS REQUIRED: YES NO
COMPLIES WITH COUNTY STANDARDS FOR DEED CREATK)N: YES NO
COMMENTS/CONDITIONS:
(�/c2Ar ► S � Ipnr�S � I l
PARCEL CREATION BY MAP
DATE OF RECORDING Z 1-7 LOT -7 BOOK 38 PAGE I -7
COMPLIANCE WITH OLD SUBDIVISION LOT ORDINANCE REQUIRED? (MAP RECORDED PRIOR TO BOOK 17 OF MAPS AT
PAGE 23): YES NO . IF YES, MARK APPROPRIATE ITEM(S) BELOW:
A. Construct road to B. Meet parcel size required by zone. C. Meet current E.H.D. requirements.
CHECK SPECIAL CONDITIONS WHICH APPLY TO MAP: ALL FEES TO BE PAID TO THE BU/LD/NG DIVISION UNLESS OTHERWISE NOTED.
1. Maintain a 50 ft. building setback from centerline of road.
' r
X2. Maintain a 20 1 building setback from rig ht-of-way/e®atexIine of 0— RZe S 1-0 �j P -d A-0
3. Pay water tender fees in the amount of $ to Battalion Number of the Butte County Fire Department. +
4. Automatic fire suppression sprinkler systems shall be installed in all residential structures in accordance with the National
Fire Protection Association Standard for the installation of sprinkler systems in one and two family dwellings and mobile
homes, NFPA Standard 13D, unless a pressurized community water system, with hydrants that meet Fire Department
specifications,. serves .the .parcel.
5. Pay T.D.D. (Thermalito Drainage District) fee in the amount of $
6. Maintain a 100 ft. leachfield setback"from all existing wells.
7. Maintain a ft. leachfield setback from
8. Meet the requirements of the Department of Fish and Game for the preservation of oak trees.
9. A traffic mitigation fee for each new or additional living unit shall be paid. Pay the amount of $ as stated
in the Oroville Area Traffic Mitigation Fee Agreement. Payment to be made to the Planning Division.
10. All.new residential buildings shall be constructed to comply with the requirements of the Uniform Building Code for seismic
safety. Mobile homes shall be constructed on a permanent foundation system which complies with the Seismic Zone 3
requirements of the Uniform Building Code.
11. Deer Mitigation fees are to be paid, if such fees have been adopted by the Butte County Board of Supervisors.' I
C 12. MAJ NT -A-1 N At 2 5 1 " d 0 ) (- a1 N6 S-67-AIAG14- W Ny5 Fr" rt5 -%;i!
R -t (,t -t --r— -mF - wr+� . (�( N11� or- Whr2TN 4E_c.L Cr, (50':
CHECK APPROPRIATE REQUIREMENTS YES OR NO OR CONDITION NUMBER.
LD 12194 - CAWP51\f0RMS.KI8L0GPERM.CLR
> i3, Sa� 38 M 1"7 rot?-- c.ocfrn,orJ Or- IPU, C Iz �.
A13�aZd,uniKor. ' .
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