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School District
A.P. Number
Property Owner
BUTTE COUNTY SCHOOLS IMPACT FEE CERTIFICATION FORM
(One fo m,,--p�eerr Building)
Building Department No.
Jurisdiction: City County
-- /— -
Propel Location/Address
Subdivision
Residential Development
No df Living Mobile
Units Installation
Commercial/Industrial
New
�r
Building Department Representative
t
Lot No.
...............................................................................................................
i Sq. Footage
Aii�" *Supplemental to l
Conversion Permit#% ., I
*(No fou�ndallob nsrpection)
............................................................:......._..$........:......................
I 1 ` 1
Adel
moor vans reviewea oy ocnooi uisinci rersonneu
District Identification No. 15-192.
r5gq,
(Group R)
fi
-,Sq. Footage h, .
(Including Exterior
Roofed Areas)
�-2&-o-
Date
6" tir; (� Q Fla „� School District certifies that
(LApplicant)
e
(Street Address) (Phone Number)
V,-, J,- G._A S`1 6 t.
(City) (State) (Zip Code)
has complied with the requirements of Resolution No. p r< . a 1 „ 10 by payment of $ V
representing 34 square feet. / AB 2926 $
FULL MITIGATION $
School District Representative Date
Paid by Check # "�� > Remarks: 3 4
i
Notice: You may protest the imposition of the fees identified above by submitting a written protest to the District, in compliance with
Government Code Section 660201a), within 90 days from the date fees are paid. Failure to submit a timely written protest will prohibit
you from challenging the imposition of the fees in any court action.
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 fully mitigate its impict on the school district's schools.
White (applicant), Yellow (budding department), Pink (school district) feeform.xls (10/98)dmm
OWNER -BUILDER VERIFICATION
Attention Property Owner:
An "owner -builder" building permit has been applied for in your name and bearing your signatm.
Please complete and return this information at your earliest opportunity to avoid uanecessary delay
in processing and issuing your building permit. No building permit will be issued until this
verification is received.
1. I personally plan to provide the major labor and materials for construction of the proposed
property improvement: YES 0," NO O
2. I HAVE 0`�` HAVE NOT O signed an application for a building permit for the proposed wodc.
3. I have contracted with the following person (firm) to provide the proposed construction:
NAME:
ADDRESS:
PHONE:
CITY:
CONTRACTOR'S 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:
PHONE: CONTRACTOR'S LICENSE NO.
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:
PROPERTYOWNER:S�rE� �1
SOCI,AL SECURITY NUMBER:
DATE: re i k9 � o�-
NOTE: Thu Owner -Builder Verification is required by Section 19831 and 19832 oftike
California Health and Safety Code. This verification mast be completed Md
returned to our office before we are permitted to issue the permit
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