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Home My WebLink About071-430-001BUILDING DIVISION COUNTY OF BUTTE - DEPARTMENT OF DEVELOPMENT SERVICES 7 COUNTY CENTER DRIVE – OROVILLE, CALIFORNIA 95965 – TELEPHONE: (530) 538-7541 AGRICULTURAL BUILDING EXEMPTION PERMIT PERMIT NO. Agricultural building is defined as follows: Agricultural building is a structure designed an constructed to house farm implements, hay, grain, poultry, livestock, or other horticultural products. This structure shall not be a place of human habitation or a place of employment where agricultural products are processed, treated, or packaged, nor shall it be a place used by the public. ( I ASSESSOR PARCEL NO. 071- 413o- no I ZONING OWN e P ONE NO. o- 3��_66 2 MRAD SS^�–� ,6 O F�5�/�� LOCOF 'x;'DI n �. I�S Iq USE OF BUIJ�D NG /C O/4 SIZE OF STRUCTURE XSO. FT. TYPE OF CONSTRUCTION: WOOD FRAME --)(— STEEL CONCRETE OTHER (Specify) TYPE OF SIQJ7�E �� ROOF COVERING FL R TYPE ESTIMATED COST OF CONSTRUCTION $ zo, o la cy AG Buildings shall comply with the minimum front, side, and rear yard setback requirements of the applicable County Ordinances as follows: FRONT SIDES �26REAR ao AG Buildings shall be a minimum of five (5) feet from any septic tank or leach fields. AG Buildings less than 1000 sq. ft. in floor area shall be located a minimum of 6 feet from a residence, 10 feet from a mobilehome, and 23 feet from a commercial building. AG Buildings greater than 1000 sq. ft. in floor area shall be located a minimum of 23 feet from a residence and a mobilehome, and 40 feet from a commercial building. I declare under penalty of perjury that the building will be used as stated about, and the purposed use confirms with the AG Building definition. If any change in use or occupancy of the buildinJ�gi is made, I will contact the Building Division and obtain any necessary permits, inspections, and approvals to co/ the require r�t is in effect at that time and before occupancy. /h /I �� l Date Q Permit ee -$9.98 Receipt No. A22 "c% � Kq ) 1 Signature of The above described AG Bui Manager Building ision By White — DPW, Yellow — Assessor, Pink — B. I., Goldenrod — Applicant is exetrot from a building permit. Date a a it r ! BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT 24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO) ` OFFICE #: (530) 538-7541 FAM (530)538-2140 WEBSITE: www.buttecounty.neAdds PERMIT NO. �BP042199 LICENSED CONTkACTORS DECLARATION' I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of Issued Date: 07/28/2004 APN- 071-430-001-000 the Business and Professions Code, and my license is in full force and effect. License Class : License Number: Site Address' Date: Contractor. Map Index: i Description: ELEC SVC FOR WELL 8r FUTURE LOT O INER-BUILDER DECLARATION I from the I hereby affirm upAr penalty of perjury that am exempt Contractors' Sta&o License Law for the following reason (Sec. 7031.5 DEVELOPMENT Business androfessions Code: Any city or county which requires a permit to cons ruct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a Owner: PHILLIP HERZENACH signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or 2120 E LA MADERA DR she is exempt therefrom and the basis for the alleged exemption. Any TUSCON AZ 85719 violation of Section 7031.5 by any applicant for a permit subjects the than five hundred dollars ($500).): �, applicant to a civil penalty of not more .CJ1&3&y 326-6669 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does Applicant: PHILLIP HERZENACH such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If however, the building or improvements are sold within one 2120 E LA MADERA DR year of completion, the owner -builder will have the burden of TUSCON, AZ 85719 proving that he or she did not build or improve for the purpose of 696 fj" 326-6669 sale.). Ek/ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code. The Contractors' State License Law does _ not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed Contractor: HURST, MIKE pursuant to the Contractors' State License Law.). ❑ I am Exempt under Article 3 of the Business and Professions Code - 15 OAKCREST DRIVE OROVILLE, CA 95966 Date: Owner: 530-589-5330 . R MIKE-TERRI@SBCGLOBAL.NET . WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: License #• 335967 ❑ 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. Architect: ❑ I have and will maintain workers' compensation insurance, as required by Section 3700 the Labor Code, for the performance of FnninP_P-r_ the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: OFFICE COPY Carrier: Address Policy #: Total S � V GAS usf 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 Cent Meter By Date become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' of ELECTRIC Meter By Date compensation provisions of Section 37d0 the Labor Code, I shall forthwith comply with those provisions. Date: o aO0 Applicant: WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor code, interest, and attorney'fees. fee �" _ - CONSTRUCTION LENDING AGENCY This permit is hereby issued under the applicable provisions of the Butte County CodA anrVpr I hereby affirm that there is a construction lending agency for the Resolutions to work indicated abo which fees have.been paid. performance of the work for which this permit is issued (Sec 3097 Civ.) i� `� m�p`� Date: / ^ OL Name: By-v�/��,/, G PERMIT EXPIRES ON: Address: Date ❑ I hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage, handling and use of hazardous materials. ❑ Notification in accordance with Section 19827.5 of California Health & Safety Code is not applicable to the scheduled construction of this project. ❑ Attached are copies of the required E.P.A. notification forms. I hereby certify that I have read this application, that the above information is correct, and that I am the owner or the duly authorized agent of the owner. I agree to comply with all county and state laws relating to building construction. I acknowledge it is unlawful to alter the substance n ficial form or do ument of Butte County. I hereby authorize replies natives of Butte County toter upon the above mentioned property for inspection pur ses . Print Name: Signature: Date: 0 Owner ❑ Contractor ❑ Agent for Owner ❑ Agent for Contractor . BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT 24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO) OFFICE #: (530) 538-7541 FAM (530)536-2140 WEBSITE: www.buttecounty.netWds PERMIT NO. BP042199 LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of Issued Date. 07/28/2004 APN• 071-430-001-000 the Business and Professions Code, and my license is in full force and effect. License Class : License Number: Site Address: Date: Contractor. Map Index: OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Description: ELEC SVC FOR WELL & FUTURE LOT Contractors' State License Law for the following reason (Sec. 7031.5 DEVELOPMENT Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a Owner: PHILLIP HERZENACH signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or 2120 E LA MADERA DR she is exempt therefrom and the basis for the alleged exemption. Any TUSCON, AZ 85719 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).): (530) 326-6669 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does Applicant: PHILLIP HERZENACH such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If however, the building or improvements are sold within one 2120 E LA MADERA DR year of completion, the owner -builder will have the burden of TUSCON, AZ 85719 proving that he or she did not build or improve for the purpose of sale.). (530) 326-6669 LY/I. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code. The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed Contractor: HURST, MIKE pursuant to the Contractors' State License Law.). ❑ I am Exempt under Article 3 of the Business and Professions Code 15 OAKCREST DRIVE OROVILLE, CA 95966 Date: owner: 530-589-5330 MIKE-TERRI@SBCGLOBAL.NET WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: License• 335967 ' 131 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 Architect: required by Section 3700 the Labor Code, for the performance of Engineer: the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: Total Square Ft: 0 S. F. Policy #: a✓ U� I certify that in the performance of the work for which this permit is Valuation: $0.00 issued, I shall not employ any person in any manner so as to Census Code: 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. " ,?,s>-- o?eo Date: Applicant: WARNING: Failure to secure workers' compensation coverage is ` unlawful, and shall subject an employer to criminal penalties and one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor code, interest, and attorney's fees. CONSTRUCTION LENDING AGENCY This permit is hereby issued under the applicable provisions of the Butte County Coda and/or I hereby affirm that there is a construction lending agency for the Resolutions to o work indicated abo which fees have been paid. performance of the work for which this permit is issued (Sec 3097 Civ.) (�l Name: B : 1 (, Date: y� PERMIT EXPIRES ON: 7 - 9 2'A417 Date Address: ❑ 1 hereby certify that the use of this facility shall comply with Sections 25505, 25533, and 25534 of the California Health and Safety Code, which regulate the storage, handling and use of hazardous materials. ❑ Notification in accordance with Section 19827.5 of California Health 8 Safety Code is not applicable to the scheduled construction of this project. ❑ Attached are copies of the required E.P.A. notification forms. I hereby certify that I have read this application, that the above information is correct, and that I am the owner or the duly authorized agent of the owner. I agree to comply with all county and state laws relating to building construction. I acknowledge it is unlawful to alter the substance n ficial form or d ument of Butte County. 1 hereby authorize rep res natives of Butte County toe ter upon the above mentioned property for inspection pu ses . Print Name: Signature: Date: — ❑ Owner ❑ Contractor ❑ Agent for Owner ❑ Agent for Contractor BUTTE COUNTY DEPARTMENT OF DEVELOPMENT SERVICES BUILDING PERMIT APPLICATION AND SUBMITTAL REQUIREMENTS 24 HOUR INSPECTION#: OROVILLE: (530) 538-7636 • CHICO: (530) 891-2834 OFFICE #: (530) 538-7541 A FEE WILL BE REQUIRED AT TIME OF APPLICATION "PLEASE PRINT CLEARLY" CONTRACTOR OWNER Last Add s oa .E Z A Ci &c � Stat z Z�s P ne 3,20 Fax .2 - 3o2G - (66-8S' Fax E-mail CONTRACTOR Name �: G Address Address City J State,4 5 AE o Zip Phone Phoned ^ sw s-3 �o Fax E-mail Lic. # Class For office usoAW ARCHITECT/ENGINEER Name Flood Zone Address J: Z City L� State Zip Phone Book. Fax E-mail 3�G _65b'S State License Number For office usoAW APPLICANT NAME Name Flood Zone iL J: Z Address O L� Ci Type Const Stat�42_ Book. P one 3,2&,— 6o2v� 3�G _65b'S E -m '1 For office usoAW Zoning Property Address p �S of Flood Zone Cross Street SRA I Yes I No Occ. Type Const Subdivision Name Map Book. Page Lot# Planner Date Approved: PERMIT NO. BPo4 s BIN # LOCATION AP# O 71 -- Y,3 a -- Property Address p �S of 1 City /3er Cross Street 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 1'73o . , �7Zc. -V, , /�Zz 7/F- ?- f M Description or S o e of o O Sq. Footage ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): EXPIRATION OF APPLICATION Applications for which a permit has not been issued will expire one year after the date of application. In order to renew action on an application after expiration, a new application, plans and fee will be REQUEST FOR REFUNDS Refunds can only be made upon written request by the person who paid the fee. The request must be made prior to the expiration of the permit and no construction work has been done. Filing fees, plan check fees for work plan checked and other department costs are not refundable. Received by: 4<C `- Amount l I O Bldg I Receipt #: ¢p69 6 4- OVER FOR SUBMITTAL REQUIREMENTS L K:IFORMBUILDING F0RMS\B1dgApp1SubRgmts.doc Page 1 of 2 Date: 7. _j3.04 SRA Sheriff SMIP Other 1(0-- Total REV 6-16-04 `i SUBMITTAL REQUIREMENTS The following drawings and specifications must be submitted to the Building Division in order to apply fora permit. INCOMPLETE SUBMITTALS WILL NOT BE ACCEPTED. ALL PLANS MUST BE LEGIBLE AND IN INK. Residential, New, Remodels, Additions, and Accessory Structures: ❑ 1. 3 Site Plans, signed by the preparer. NO GRAPHPAPER! ❑ 2. 3 Complete sets of plans, signed by the preparer. NO GRAPHPAPER! OR 3 Sets Engineered plans (if required) with wet signature on plans AND 2 sets of stamped and signed calculations. ❑ 3. 2 Engineered truss details and layouts (if required) (NO FAXES!). '❑ 4. Letter from Engineer or Architect for truss design review. ❑ 5. 2 Energy compliance design and supporting documentation. (Note: Not required for additions to mobile or modular homes.) ❑ 6. 2 Flood Elevation Certificate, wet -stamped and signed (if required). ❑ 7. Detached Accessory Building Form, filled out by the property owner (if required). ❑ 8. Sanitation and site plan approval from the Environmental Health Department. ❑ 9. Metal Buildings: (A) Metal Bldg Plans, (B) Fnd plans and calcs in triplicate, (C) Elevations in triplicate, (D) Floor plans in triplicate, All of these must be stamped and wet -signed by the engineer. Mobile, Manufactured, or Modular Homes: ❑ 1. 3 Site Plans, signed by the preparer. NO GRAPHPAPER! ❑ 2. 2 Data sheets and installation instruction manual. ❑ 3. 2 Marriage line information. ❑ 4. 2 Floor plans. ❑ 5. 2 Engineered Tie Downs or Foundation plans. ❑ 6. Sanitation and site plan approval from the Environmental Health Department. ❑ 7. 2 Flood Elevation Certificate, wet -stamped and signed (if required). Commercial, New, Additions and Remodels: ❑ 1. 4 Site Plans, signed by the preparer. NO GRAPH PAPER! ❑ 2. 4 Engineered plans with wet signature on plans AND 2 sets of stamped and signed calculations, with code analysis. ❑ 3. 2 Engineered truss details and layouts (if required) (NO FAXES!). ❑ 4. Letter from Engineer or Architect for truss design review. ❑ 5. 2 Energy compliance design and supporting documentation (if required). ❑ 6. - 2 Flood Elevation Certificate, wet -stamped and signed (if required). ❑ 7. Statement of Intent for Non -heated and A/C (if required). ❑ 8. Metal Buildings: (A) Metal Bldg Plans, (B) Fnd plans and calcs in triplicate, (C) Elevations in triplicate, (D) Floor plans in triplicate, All of these must be stamped and wet -signed by the eneer ❑ 9. Letter of intent. ❑ 10. Hazardous Material Form. ❑ 11. Sanitation and site plan approval from the Environmental Health Department. If you have questions or would like additional information regarding this process, contact a Permit Application Assistant at (530) 538-7541. OVER FOR BUILDING PERMIT APPLICATION KAFORMSWILDING F0RMS\BIdgApp1SubRgmts.doc Page 2 of 2 REV 6-16.04 1 COUNTY OF BUTTE -DEPARTMENT OF DEVELOPMENT SERVICES -BUILDING DIVISION 7 County Center Drive, Oroville, CA 95965 Phone (530)538-7541 Fax (530)538-2140 PERMIT APPLICATION DATA SHEET OWNER: 4e12 Z E t. I At -c_- o~t ASSESSOR PARCEL NUMBER 4=� 7 f' 3 et, o I La T" DC_V ESL • e� Proposed Building Use: ELEC FOR VV C-2 L. -+- F_ -7 I. TLL2 Eounter Technician: ��1 Date: �' � 3 Items required in order to apply for a permit. All boxes MUST be checked OR marked NA in order to apply. O 1. Site plans, 3 or 4 sets, signed by the preparer of the plans. . ❑ 2. Complete plans, 3 or 4 sets, signed by the preparer of the plans. ❑ 3. Engineered plans, 3 or 4 sets, with wet signature on plans AND 2 sets of stamped and signed calculations. ❑ 4. Engineered truss details and layouts in duplicate. No faxes! ❑ 5. Letter from Engineer or Architect for truss design review. ❑ 6. Energy compliance design and supporting documentation in duplicate. ❑ 7. Statement of Intent for Non -heated and A/C for Non -Residential Buildings. ❑ 8. Manufactured homes: (A) Data sheets and installation inst, (B) Marriage line info, (C) Floor Plan, (D) Tie down or fnd plans, all in duplicate. ❑ 9. Metal bldgs: (A) Metal Bldg Plans, (B) Fnd plans and calcs in triplicate, (C) Elevations in triplicate. (D) Floor plans in triplicate. All of these must be stamped and wet -signed by the engineer. ❑ 10. Flood Elevation Certificate, wet -stamped and signed, in duplicate ❑ 11. Site plan and business license approval from the City of Biggs ❑ 12. Letter of intent for non-residential buildings ❑ 13. Detached Accessory Building Form filled out by the owner ❑ 14. Hazardous Material Form ❑ 15. Sanitation and site plan approval from the Environmental Health Department in ❑ Chico ❑ Oroville, as applicable. ❑ 16. Other Remaining items needed to issue the permit. (May require additional plan review upon receipt of the following items.) ❑ 17. Fire Sprinklers............................................................................................ ❑ 18. Agricultural Buffer clr and site plan apr from the Ag Commissioner Sent by ❑ 19. Soils Report and/or Engineered Foundation required ................................................... ❑ 20. Erosion Control Plan Required........................................................................ ❑ 21. Fees as shown on the attached Schedule of Fees Due Sheet .............................. ❑ _ 22. City of Chico Plumbing permit........................................................................ ❑ 23. California Department of Forestry plan approval ❑ paid. Sent by: ............. D� 24. Planning approval (A) Use: (B)Parking: (C) Parcel Check: ❑ 25. Contact Land Development about _ Improvements, _ Drainage ......................... 0 26. NPDES Form.................................:........................................................... 27. Encroachment Permit for driveway from the Public Works Dept .......................... 28. Pre -Inspection for E LEc ry R w r1LL a- F-c.u-rL r! fequlred.T.... -D eV L o N r--(&x.r-r ❑ 29. Contractor's license information. (Number, Name Style, Classification) ................... ❑ 30. Worker's Compensation Carrier and Policy Number .......................................... ❑ 31. Owner -Builder Verification (_ Given to owner, _Mailed to owner) ..................... ❑ 32. Letter of Signature authorization."...................................:............................. ❑ 33. Recorded copy of Agricultural Acknowledgment Statement ................................. ❑ 34. Manufactured home utility clearance .............................................. :................ ❑ 35. Existing violations and/or expired permits......................................................... ❑ 36. Deed Restriction......................................................................................... ❑ _ 37. ❑ Grant Deed, ❑ M.H. Title/Statement of Facts, ❑ Letter from Legal Owner, ❑ Check to H.C.D. $ �. 38. Other: LETTIs oC 4C) F' ArL.r-rH FoR 1 -1I -L00. *-r >-tC-< -ro ❑ 39. Other: When issued Telephone 5-70 - X754.95 14-5 and hold for pickup. I have been inf6r' e f t.. a b6ve items and requirements for obtaining a building permit. . 7/) 14�1 Date: 1. Index perryfit 5pplica'C}6 fo(the a�a e items numbered: 2. Additional items req(ii ed_ Contractor, designer, owner, was advised of the above data by ❑ phone, ❑ mail, ❑ counter, by Contractor, designer, owner, was advised of the above data by ❑ phone, ❑ mail, ❑ counter, by Plans reviewed by: Date: Plans approved by: Structural reviewed by: Date: Structural approved by: Note transfer by: Date: Yellow: Building Division _ Plan Check letter Date: Date: Date Date: 1 - � ` " i .. _ \ ` i \" � - � • �' �, � i'r' �. � � �� PRE -INSPECTION REPORT , 1I OWNER: 44,je ze-0 Arcs-+ DATE: LOCATION: tom] 0vERM SP 12 1 X1 &5 ko Bee.,Ly A.P. # 4D71. 43a • oo t ' -CONTRACTOR: ZONING: REASON FOR PRE -INSPECTION F;Ci2 Wei,i_ -w t Zt7l.t,I2E �T h/. DATE TO INSPECTOR: 7 a40 PERWr HISTORY (X) NONE () SEE ATTACHED BUILDING INSPECTOR'S REPORT Building Description: Commercial/Usage: . Residential # of Units: r Mobile home # of Units: Currently Occupied ( ) Yes ( ) No Abandoned/Vacant: Electric: Electric Currently ( ) On Condition of Electric 'Gas: Currently ( ) On Condition Sanitation: Plumbing Worldng O Yes Obvious Sewage Problems ( ) Yes ( )Off.; i ( ) Off ( ) No ( ) No ACTION RECOMN[ENDED: • ISSUE (,Iles O No Hold for permits or verify: 4 zo a MOO i.,) n J), Inspector: /U L / Date: cu1Vrrf_1u RTTFT.T1TV _c nN u1P.VF,R4F, ANY) TNY)TCATF, 1,0CATTON ON PROPFRTV_ �UTp� BUTTE COUNTY 0 0 - DEPARTMENT OF DEVELOPMENT SERVICES 0 o BUILDING PERMIT APPLICATION 0 AND SUBMITTAL REQUIREMENTS o `_� o 24 HOUR INSPECTION#: OROVILLE: (530) 538-7636 • CHICO: (530) 891-2834 _ OFFICE #: (530) 538-7541 c0U N'�y A FEE WILL BE REQ UIRED AT TIME OF APPLICATION "PLEASE PRINT CLEARLY" OWNER Last a urs me /, Add S oa Z. /11x02 ZRI Address City29 o c1 'l / State�2 Pbgne666 Fa"5�o - 3.26 - (653?5 al!CFtL Sao �sy-8/Y$ r OCd CONTRACTOR Name A � : G Address Address City29 o c1 'l / State�2 5 Phone sw-- S3 &D Fax– F E-mail Cc. # Class 1/0 irm� 0 Mwawml For office us nl . ARCHITECT/ENGINEER Name Flood Zone Address J: Z City LX x A State ZIP Phone b� Fax E-mail F State License Number 1/0 irm� 0 Mwawml For office us nl . APPLICANT NAME Name Flood Zone aijl�o J: Z AddressO LX x A Cid— Type Const StateZ b� P one Lot # F E -m 'I C A. Gs 2') 9 i 1/0 irm� 0 Mwawml For office us nl . Zoning Property Address p i44111 &0 It of Flood Zone Cross Street SRA Yes I No Occ. Type Const Subdivision Name Map Book Page Lot # Planner . Date Approved: PERMIT NO. BPe�q. s 199 BIN # LOCATION AP# 0-71 -- 41,30 - 00,0 - Property Address p i44111 &0 It of City e r Cross Street 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 ofpennitissuance. LENDING AGENCY Name �(JGt'nc--IQ 01^- r Address 1730 IV, 774zc gdv'v /4z aFss Description or Scope of Work: Sq. Footage ❑ Structure Built without Permits ❑ Proposed Change of Occupancy (Note previous use): EXPIRATION OF APPLICATION Applications for which a permit has not been issued will expire one year after the date of application. In order to renew action on an application after expiration, a new application, plans and fee will be REQUEST FOR REFUNDS Refunds can only be made upon written request by the person who paid the fee. The request must be made prior to the expiration of the permit and no construction work has been done. Filing fees, plan check fees for work plan checked and other department costs are not refundable. UVtK 1 -UK SUBMITTAL REQUIREMENTS . IL K TORMS\BUILDING F0RMS\B1dgApp1SubRgmts.doc Page 1 of 2 Received by: 4< •,' "' Amount: 110-- Bldg . SRA Receipt #: ¢p / (� Sheriff SMIP • Date: Other 7.3.04 t (0-- Total' REV 6-16-04