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MELVILLE, STUART
26 EDGEMONT DR, OROVILL17
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078-330-038 06-1754 .011
.MELVILLE, STUARTTIP f•
Cs26 EDGEMONT DR, OROVILLE'
NOTES,
Cont: GALLAGHERS HEAT&AIR -
HVAC'
r RESIDENTIAL
APN`. Permit No.
Owner.
Site Address:
Contractor.
• Type of Permit:
r
f ,
• 3 -
t
-
A
SPECIAL CONDITIONS
CHECKED BY
❑ SRA
❑ FLOOD CERTIFICATE EQUIRED
Q FIRE SPRINKLERS REQUIRED
Q SPECIAL INSPECTION ITEMS
Q VERIFY
Q USE PERMIT CONDITIONS
Q SUBSTANDARD HOUSING LETTER
Q ENCROACHMENT PERMIT
Q REINSPECTION FEE PAID
Q ENV HLTH CLEARANCE
Fl•
DATE JOB FINALED:
rt —e
`SIGNATURE: 0
+=OK
o = Not OK
MANUFACTURED HOMES
': MISCELLANEOUS "
.,'l
3
DATE- PERMANENT FOUNDATION Lj SOFT -SET
'--DA3'E D E C K S'C O V E R S'C A R P O R T S •GARAGE S
1 ZoningSetbacks-Easements
2 Ftgs; Soils•Sz-0pthSpacing-CnnctrsSteel
1 Zoning -Setbacks -Easements.
2 Soils; Special MH Support Sketch
3 Sewer; Loctri-Test; FaIVCIO-Concrete
3 Decks, Girders1Jolsts-0cking-Brcing
4 Wtr, Loctn-Test-Easeinent Needed -Regulator
Stairs-GuardlHandralls r
5 Elec Loctn-CIrncs-Concrete-0oncrete
4 Wood Awn; Posts-Beams4bas-CnnctrsShttig.
6 Yard Gas; Loctn-Test Wrap i 4 Nat ❑ or LPQFrmg-Brcng
_
'
Inch Sz Ft Lngth" -
5 Alum Awn; Columns-CnnctnsSpllce-0ecal-Enclsrs
7 Blckng; SzSpacing-Marriage Ltne
'6 Carports; Wndws-Doors '
8 Gas; MH Test-Demand-Valve-0nnctr
7 Electric
9 Elec MH Cntnty Test-Crossovers-Breakers•Clmcs
8 Frmg; Sills-AnchrsStuds4bas Tnisses
10 Drain MH Test -Fall -Flex Cnnt tr
9 Siding; Nailing -Veneer -Stucco -Lath
11 Wtr & Sewer Connected -CIO to Grade
10 Root, Shthg-Roofing
12 Gas and Electricity Tagged ' '
I I Ext; Steps -Doors -Landings
13 Tie Downs , E Foundation . ❑
12 Braced Wall pnis .
14 Exits
T 15 Cert of Occupancy
16 HUD Label/Insignia Numbers Serial Numbers
DATE POOLS
1 Setbacks -Easements «
'
2 Soils; Compaction -Structure Stability
`
3 Pool Structure; Steel-Cnnetns-T_ hickness
Dead_ Men4Jning
4; Elec ReptelslLting; Distance -GR
'
de v? dA- �a
5 Elec Pool Lting; IS volts-0FI
6 flec.Endsrs; Conduit Entries Terminals4isted .
7 Elec Bonding; Metal w/5•CrcItng Eqp-Htr
L ,
8 Elec Gmdng; Eqp w/5' Crcltng Eqp-Pool Ightg
Box--Enclsts4idl6oardsansultn to Main Conduit
+
9 Health Dept APPM
10 "Plmb; Cir Test-Wtr Supply Test
11 Lt Niche
12 Enclsr, Fencing -Alarms
13 Bonding, Diving board or, Slide
dr d o'er, vl
3
RESIDENTIAL (Single & Duplex)
DATE JUNDERFLOOR
1 Zoning -Setbacks -Easements -Flood -Slope
2 Ftg Main; Soils-Elec Grnd Ftg Dpth
3 Ftg Garage; Soils-Steel-Elec Grnd " Ftg Dpth
4 Ftg Porches/Decks; Soils -Steel Ftg Dpth
5 Stemwalls Wain; Steel-Blockouts Wrapped
6 Stemwalls Garage; Steel-Blockouts Wrapped
6a Hold Downs and Special Anchrs
7 Slab, Steel Wrapped
8 Piers-Frpic Ftg-Steel
9 DWV; Fall -Fitting -Test -2 -way CIO -Sewer Test
10 UF, Gas Pipe; Sz Anchrs-Sz Test
11 Wtr Pipe; Test-Anchrs-RgltrService Test
12; Elec Undrgrnd
13 Plenums & Ducts; Clrnc-MaterialSupport4nsultn
14 GirdersSills-Anchr Bolts-Joists-Vnts-Cripples
15 Acc & Vntitn '
16 Insulation
lie 0
DATE JFRAMING
17 Sills Proper Materials & Anchrs
18 Walls Studs-Nailirig Spacing & Braces -Plates -Sound
19 Bearing Walls ovet Girders A fir Nailing
20 Draft Stop In Walls (rat proof)
21 Fire Stops; Furred CeilingsStairs-Chasers-Tubs
22 Headers 8 Bear sSi &'Bearing -
23 Hangers-Posf Caps-Anchrs-Cnnctns
24 Ceiling Joist-Rftr Ties-Purlin-Roof Brac TrussShthg
25 Frpic Tles or Type A Flue=Frpic Throat Clrnc
26 Attic Acc; Sz &'Rinz Prtcln-Draft Stop -Ins Baffles
27 Bdrm Wndws or Exiting Doors -Sill Ht & Dimensions
28 Garage Fire Prtciri Framing -RC Channel
29 Prprty Line Firewall & Opngs'
30 Ext Doors -One 3' -Check Garage 3rd Story, 2 Exits
31 Stairs; Width-Hdrm-Rise-Run-Landing-Fire Prtctn
32 Piywd on Roof Ovrhng Attic Vnts4ft Outrgrs
33 Siding -Nailing Veneer
34 Stucco Lath -Weep Screed-Fndtn Vnts-Undrflr Acc
35 Glazing Area -Glass PrtctnSkyLts-Plastic .
36 Shear Walls; Nailing -Bolts
37 Brace IntiExt Wall pnis
38 Insultn-Walls-Ceilings
39 Infiltration -W alis -W ndws
ya
d%
DATE JELECTRICAL
40 Fxtr & Trnsfrmr Clrnc4ns Prtctn
41 Elec Rcptcls Spacing-Lts & Switches at Doors
42 Sz Boxes & No Of Cndctrs Stapled
43 Romex Installed Close to Edge of Studs & CJ
44 Eqp Grnd made up w/Mech Fstnrs
45 Gmdng Electrode Bond Gas & Wtr
46 2 Appinc Cires in Ktchn & Cndctr Sz GFl
47 Subfeed Wire Sz ya QCU or ❑AL
AC Wire Sz Q CU cr ❑ AL
48 Range Circ ❑ CU or ❑ AL
Oven Circ ya Q CU or ❑ AL
Insulated Neutral [—]Yes ❑No
49 Service -Riser Cndctrs & Grnd Main Dscnnct
50 Eqp Clrncs pnls-Motors-Mech Eqp
51 Clothes Closet LtShwr Lt -Spa Lt
52 Smoke Detector
DATE IPLUMBING .
53 Wtr Htr; Vent-Acc-Cmbstn Air Baffle
54 Wtr Pipe; Test & Anchr-Nail Prtctn
55 DWV; Test Fittings & Anchr. Nail Prtctn
56 Shwr Pan; Test, First fir -Tub Acc
f 57 Test Tubi & Shwr, 2nd fir - Tub Ace
58 Gas Pipe; Sz & Anchrs
59 Fire Sprinkler; Test
60 Yard Gas Piping
DATE IMECHANICAL
61 AC Ducts In' ultn & Support
62 Vent Fan, Exhaust abv Insulin
63 Condensate Drain & Ovrnw, Sz & Grade
64 Furnace -Vent Acc-Comb Air Rtrn/Vent 115 Outlet
65 Attic Acc & Pltfrin if Furnace In attic
o•� �s} o+r �y'
DATE IFINAL
66 Ext Steps -Door & SideLt Prtctn-Landings
67 Smoke Detector
68 Furnace Vnts-Clmc-Comb, Air-Cnnctr
In Garage; abv-fir-Ducks-Meth Prtctn
69 Bedroom Exiting
70 GFl & Bath Fxtrs & Tub Acc-Spa
71 GFI Arc Fault
72 Elec Trim & Subpnl, Breaker Szs & Labels
73 Stairs, Guard/Handrails
74 Frpic or Stove, Clmc-Hearth
75 Elec Outlets at Wood Pnl, Int & Ext
76 Ktchn, Fxtr & Appinc; Gmd-Air-Gap-Cooking Clmc
77 Elec Outlets & Rcptcls at Ktchn Counter
78 Garage Fire Door, Swing -Landing -Closure
79 AC Duct In Garage -Damper.
80 Wtr Htr; Vnts•Clmc-Com Air Cnnctr-PRV; abv fir
Mech Prtctn; LPG Appince Undr House 3" drain
81 Plmb; Elec & Mech Eqp Listed for Loctn
82 Elec Rcptcls in Garage (GFl) Romex Prtctn
83 Insultn-Foam-Looked in Attic
84 Guard Rails & Deck Cnstrctn-Post Caps
85 Fndn Vnts & Crawl Hole Door Drnge & Wood -Earth
86 Clmc Dmge Planters Q Yes ❑ No
87 Stucco Brown -Finish
88 AC Unit Dscnnct, Elec-Plmb
89 Vnts abv Roof, PImb-Appinc-Frpic-Clmc to Opngs
90 Wtr Well, Dscnnct, Elec, Plmb
91 Ext Elec Trim, GFl Rcptcl-Undrgmd
92 Vntitn thru House
93 Glass Prtctn
94 Corrections from previous Irispctns
95 Gas Test -Meters Tagged, Gas-Elec
96 Wtr & Sewer Cnnctd-CIO to grade -HD Apprvl
97 Energy Cmpinc Cert -Other Certs
98 Address Posted
99 Fire Sprinkler
} M M
� 4+ � "Af t' lel M.s:.•'�� ,OV7f1.i� . 1
An installation certificate is required to be posted at the building site or made available for all appropriate inspections: (The
information provided on this form is required) After completionof final inspection, a copy-niust.beprovided to the building-
department (upon request) and the building owner at: occupancy,,per Section 1. 04 03(a).
HVAC SYSTEMS:
Heating Equipmew t
Cooling Equipment
Equip Type
k .. heat -pump),
CEC Certified -Mfr.
Name and: Model-
Number
#' of
Identical
Systems
Efficiency
(SEER or EER)1.
ZCF=1R value .
Duci
Location
attic etc.
Duct
:R -value
Cooling:'
Load.
btu/tir .
Cooling
Capacity
Blufht
Equip.Type
CEC Certified Mfr.
Name and sModel
# of
Identical
M
Effie ienc y i
(AFUE, etc.)
Duct
Localion
Duct or
Piping'
Heating'
Load
Heating
Capacity?
kg. heat- UMP)"Number
systems
2CF-]R value)
attic etc.
R -value
Btu/titi
Btulhi
Cooling Equipment
Equip Type
k .. heat -pump),
CEC Certified -Mfr.
Name and: Model-
Number
#' of
Identical
Systems
Efficiency
(SEER or EER)1.
ZCF=1R value .
Duci
Location
attic etc.
Duct
:R -value
Cooling:'
Load.
btu/tir .
Cooling
Capacity
Blufht
P_acRa - C +_Gast
R d3
-� X71
1C 40
At ttic3
C4
3: 03
0
1.:> symbol reads greater'than or equal to what is indicated on the CF-IR'value.
Include both SEER and EER if compliance credit for high EER air conditioner is claimed.
011, the undersigned, verify that equipment: listed above is: 1) is the actual e4uipment installed, 2) equivalent to or
more efficient, than that :specified in the certificate of compliance _, (Form. CF -1 R)' submitted for compliance :with the
Energy Efficiency Standards for residential buildings, and 3) equipment that meets or exceeds -the appropriate
'requirements. for manufactured devices (from the'Appliance'Ifficiency Regulations or Part 6)1, where applicable.
Installing: Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner.
GaliagherAir
Signature:
Date: 08/021.061
• ��iecuonicany signea)�
Copies to: BUILDINGDEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY
F R a
Residential Comp1. liance Forms April 20055:
INSTALLATION CERTIFICATE (Page 4 of 12) C1F-6R
Site Address Permit Number
,24_Edgemount_D.r_O.roville-CA-95966 SP_0617.5.4
INSTALLER COMPLIANCE STATEMENT FOR DUCT LEAKAGE
INSTALLER COMPLIANCE STATEMENT
The building was: ✓ W, . ested at.Final ✓ ❑ Tested at Rough -in
INSTALLER VISUAL INSPECTION AT FINAL CONSTRUCTION STAGE:
K] Remove at least one supply and one returnsegister, and verify that the spaces between the register boot and the interior
finishing wall are properly sealed.
❑ If the house rough -in duct leakage test was conducted without an air handler installed, inspect the connection points
between the air handler and the supply and return plenums to verify that the connection points are properly sealed.
❑ Inspect all joints to ensure that no cloth backed rubber adhesive duct tape is used
❑ New Distribution system is fully ducted (i.e., does not use building cavities as plenums or platforms returns in lieu of
ducts).
✓ 13 DUCT LEAKAGE REDUCTION
Procedures far rwZd VeriTcation mi d diagnostic tonhn9Ofair distribution .CY.C1Pnr.Q arP avai/ah1P in RArAf Ann"Xy Af a 2
NEW CONSTRUCTION:
Duct Pressurization Test Results (CFM @ 25 Pa)
MeasuredValues
1
Enter Tested Leakage Flow in CFM:
Fan Flow: Calculated (Nominal: ✓ IX,Cooling ✓ ❑:Heating) or ✓ ❑ Measured
2
If Fan Flow is Calculated as 400 cfm/ton x number of tons or as 21.7 cfm/(kBtu/hr) x Heating
1200
Camicityin Thousands ofBhAr output, enter total calculated or measured fan flow in CFM her
✓
3
Pass if Leakage Percentages 6% for Final or 5 4% at Rough -in:
❑ Pass ❑ Fail
100 x Line # 1 / ine # 2)11
ALTERATIONS:
Duct System and/or HVAC Equipment Change -Out
Enter Tested Leakage Flow in CFM from Pre -Test of Existing Duct System Prior to Duct
4
System Alteration and/or Equipment Change -Out.
Enter Tested Leakage Flow in CFM 'from Final Test of New Duct System or.Altered Duct
5
S stem for Duct System Alteration and/or Equipment Chan a -Out.
Enter Reduction in Leakage for Altered Duct System.
6
(Line # 4 Minus C57J(Line # 5 —(Only if Applicable)
7
Enter Tested Leakage Flow in CFM bo Outside (Only if Applicable)
Entire New Duct System - Pass if Leakage Percentage _< 6% for Final
8
100 x . r r i (Line # 5 /jam— Line # 2
�4 8
FX -?ass ❑ Fail
TEST OR VERIFICATION STANDARDS: For Altered Duct System and/or HVAC Equipment Change -
Out Use one of the followingfour Test or Verification Standards for com fiance:
9
Pass if Leakage Percentage 515% [100 x [ (Line # 5) / (Line# 2)]]
❑ Pass ❑ Fail
10
Pass if Leakage to Outside Percentage 5 10% [ 100 x [_(Line # 7) / (Eine # 2)]]
❑ Pass ❑ Fail
Pass if Leakage Reduction Percentage > 60% [ 100 x # 6) / (Line # 4)]]
11
_(Line
and Verification b Smoke Test and Visual Inspection
❑Pass ❑Fail
1?
PE
Pass if Sealingof all Accessible Leaks and Verification b Smoke Test and Visual Ins
❑ Pass 13 Fail
Pass if One of Lines # 9 through # 12 pass
1�'Pass ❑ Fail
V UI, the undersigned, verify that the above diagnostic test results were performed in conformance with the requirements for
compliance credit. I, the undersigned, also certify that the newly installed or retrofit Air -Distribution System Ducts, Plenums and
Fans comply with Mandatory requirements specified in Section 150 (rn) of the 2005 Building Energy Efficiency standards.
Installing Subcontractor (Co. Name) OR General
Contractor (Co. Name) OR Owner
Signature:
'tel.
Date: 0.8!_02/_0.6
(Uectronica signed)]
(lopies to: BUILDING DEPARTMENT, HERS RATER (IF APPLICABLE) BUILDING OWNER AT OCCUPANCY
Residential Compliance Forms September 2005
INSTALLATION CERTIFICATE ; - (Page, 5 of
Site Address Permit Number
'24_Edgemount_D.r_O.roville-CA.959.66 BP_0617-5--4
✓ CX] THERMOSTATIC EXPANSION VALVE (TXV)
Procedures for field verification of thermostatic expansion valves are available in RAW Appendix R1.
Access is provided for inspection. The procedure shall
OF
Location
consist of visual verification that the TXV is installed on
Outdoor.:.Unit Make
OF
✓ GXtYes ❑ No the system and installation of the specific equipment
[X]
❑
shall be verified.
Date of Verification
OF
Yes is.a ass
1 Pass.
1 Fail .
El REFRIGERANT CHARGE MEASUREMENT
Verification'for Required Refrigerant Charge and Adequate Airflow for Split System Space Cooling System's without
ThP.rmnctnfin Frrnncinn Vnlv,-e
Outdoor Unit Serial #
OF
Location
OF
Outdoor.:.Unit Make
OF
Outdoor Unit Model
OF
'Cooling Capacity
B.tu/hr
Date of Verification
OF
Date of Refrigerant Gauge Calibration
(must be checked monthly)
Date of Thermocouple Calibration
(must be checked monthly)
Standard Charge Measurement Procedure (outdoor air dry-bulb 55T and above):
Procedures for Determining Refrigerant Charge using the Standard Method are available in RA CM, Appendix RD2.
Note: The system should be installed and charged in accordance with the manufacturer's specifications before starting this
procedure.
Measuied Temperatures
Supply (evaporator leaving) air dry-bulb temperature (Tsupply, db)
OF
Return (evaporator entering) air dry-bulb temperature (.Tretorn, db)
OF
Return (evaporator entering) air wet -bulb temperature (Treturn, wb)
OF
Evaporator saturation temperature (Tevaporator, sat)
OF
Suction line temperature (Tsuction, db)
OF
Condenser. (entering) air dry-bulb temperature (Tcondenser, db)
OF
hi erheat Charge Method Calculations for Refrigerant Charge
Actual Superheat = Tsuction, db — Tevaporator, sat eF
Target Superheat (from Table RD -2) OF
Actual Superheat —Target Superheat (System passes if between -5 and +5°F) JOF
Temperature Split Method Calculations for Adequate Airflow
Salit Methnd f:nlrulatinn is #-I--
Actual
-I- ,
Actual Temperature Split = T return, db Tsupply, db
OF
Target Temperature Split"(from Tible RD3)
OF
Actual Temperature Split Target Temperature Split. (System passes if between -
3°F and +31F or, u on.remeasurement .if between -31F and: -100°F
of
Residential Compliance Forms April X05.
LRT[ PIC AT&O F F1 ELO VER[ MtATI[bN &,D[ AGNOST[C TESTING {P Age 1, of
CF4 R
P roj e --i Address
2-4-Edg6-m.-ou-nt-Dr-O.ro.v.iII6--CA- .959661
'B LLJ I der Na me
Bvildef Contact 'I n sta I I i mg---C6-n-tFa-ct - -
Z;e-f'-s-A-i rl
Telephone.
Plan Number
`HWS Rater
-H 6 -m-e - E n -a I a -s -y -s I
Telephone
i760=7-68=32281
Sam leOroup NLLmW
ir,
-Co mpl iance Metbod (Pr em; i Pti 46)
ClimateZone
5C57i
Cex , (ifying SighaiLre.
TE—lectronically!sIgned)l
0,8Z02/06
Sample House Number'
'. 1 1,
4. 8 -5-91
ETalasys-c-o-rpl
HEM Provider
CBPCA
7
Street Address:
250 CamDMDA-yel
citAl'tatelzip':
y
Calexico CA
922311
topjesto: BUIWK4K,,HV-M rKUIV.W.ER,AND MUIFLDYKG DEPARTMENT
HERS RATFR.COMI?Li-.kNC-F,'ST'AT^FPAFNt-
'rhe house was:,-/ 0 Tested %( 0 App7bYed as pari oFsample, testing, but wag not icaled
As the HEM ratdrprovidin,& z1bgrimirtefffing and fiEM,verification lbenify %ttbe.bouse, identified on this form complies-witli
thediagnoaticiesUedcompllaneerequirementsaschecksd+eon'thitdorm.TheHERSrawmustcheokantiverifyAbatthe new
distribution system is fully dwAed and correcA Uipe is used be&re a CF -4R maybe released on every tested building. TteHUM
rater must not releaselbe CF -4R until a, properly completed a nd signed CP -6R bas been received W IFe-sampleand taud,
buildings.
• The i nate ller has provided a copy ofCP-6R (Inabliation Certificate).
• New Distribution system is. fully ducted (i.e.,'doea not use building cavities as plen urro of platform retur6v in lieu ofducI4;
E3 New systerre wh= cloth backed, rubber adhesive duel, tape is installed, mastic and &awbaTds'im used in
combination with cloth backed, Tubber adhesive duct tape to =1 lealm at duct ccnTccticns.
V rXYVff WM REQUMEMENTS FOR DUCT LEAKAGE.
REDUCTION COMPLIANCE CREDIT
P.VbedMr&,0,jr4Id V&JStfthO)t a*ddiagAoslic IdAU40fair distribidid)t Sict"s are atwlable A RACM. AppejtdixM .3.
Owl biaRnostiel.-makage Testing Results
NEW COMMUCrION.
Dvtt?mnuri2a6on Test'Retuite(CM6 25 PS)
Measured,
Values.
Unlar Tested Leak4geF low in CPM:
2 Pan Tlow: Calculated (Nominal: teO Coolin&,V OHeating)orV OMessured
Enlef total VanTlow in CFM:
11-200
3 Pass i f Leakage Percentege 5 6% 100.4 J—(LineW 1)
0 Pass 0
ALTERATTONS! Duct System audfor HVAC Xquipnwut Ch anfe-Out
E nur Tested Leaksge Flow in CFM from CF-,6R-.PY*-.Tast O'fBxigti ng Dud System Prior 10
D udSystem Altuation a nd/,or Equipment Change - Out.
5C57i
E nvr Tested Leab%eftw in CPM: Final Test of New Duct System or Altered Duet System
for Duct SYSVA A Iteration and/or F4uipmentChange-Out..
6
R Mer Reduction in Leakage for Altered Duct System I _(Line* 4) Minus _(Line* 5)]
(Only if Applicable.)
7
Enter Tested Leakage F love in CPM to OuVide (On ly if Applicable)
a
Ent re New Duct System.- ?am i w"Isge �9 6%
f Lealcage Pe
I 00,x L r—i (L ine W 5) 1 r— Li ne * 2)71
4=8
r
X]%Vs - 0 psi I
7M OR VERMCA 7TO N SrAND ARDS.- For Altered Duct S yswn in d kr RVAC F,(p I prm eut Chante -Out
.Use one of the &1l6wip% four Test Or. MeAftstion Stiadardsfarownliante.- ,
Pass i f Leakage Percentep �9 15% (100x (—(Li ne W 5) 1
0 . fts? 0 Pail
jo
Pan if Leakage to 0 u1side Pematage 5 10%1)00A,( {Line * 7) '(LineW2)]]
0 Pass O.Fail
Panif LealAgeReduction Perceatsge2 60%(100x( {Line*6)/_(LineiN4)]]
and Verification by Smolce'TeRt and Visual Fn tion
13 Pass 0 flail
IZ
Pass if Sealingof all Appenible LedIcs and Verification by SmokeTest and Visual In pecti6n 11
7-
r , ' 7" -O
,%7z 13 %il
Pan if One.of Limes #9 fbyo-u2b 4 12 paw
0
,nC.W&WMJXU cmpuaxce rarmr
6 April 2005
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
x BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
PERMIT NO.
BP061754*
PERMITS BECOME NULL AND VOID 1 YEAR FROM THE DATE OF ISSUANCE, OR IF WORK IS DONE IN VIOLATION OF ANY COUNTY OR STATE LAWS.
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am licensed under Issued Date: 07/20/2006 APN: 078-330-038-000
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. il
License ✓ ��i % ��
Site Address: 26 EDGEMONT DR ORO
Class : License Number: 1 /
Date: 0 Contractor: l
�l n
Map Index:
OWNER -BUILDER DECLARATION
Description: CHANGE OUT HVAC UNIT
I hereby affirm under penalty of perjury that I am exempt from the
Contractors' State License Law for the following reason (Sec. 7031.5
Business and Professions Code: Any city or county which requires a
Owner: MELVILLE, STUART
permit to construct, alter, improve, demolish, or repair any structure, prior
to its issuance, also requires the applicant for such permit to file a
26 EDGEMONT DR
signed statement that he or she is licensed pursuant to the provisions of
OROVILLE CA
the Contractor's State License Law (Chapter 9 commenting with Section
95966
7000) of Division 3 of the Business and Professions Code) or that he or
she is exempt therefrom. and the basis for the alleged exemption. Any
(530) 774-4839
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):):
❑ 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 (Sec. 7044, Business and Professions
Applicant: GALLAGHER'S HEATING & AIR
Code: The Contractors' Stale License Law does not apply to an
PO BOX 35
owner of property who builds or improves thereon, and who does
such work himself or herself or through his or her own employees,
provided that such improvements are not intended or offered for
LOS MOLINAS, CA 96055
sale. If however, the building or improvements are sold within one
year of completion, the owner -builder will have the burden of
800-892-3556
proving that he or she did not build or improve for the purpose of
sale.).
\
❑ 1, 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
Contractor: GALLAGHER'S HEATING & AIR
not apply to an owner of property who builds or improves thereon,
PO BOX 35
and whU contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
❑ I am Exempt under Article 3 of the Business and Professions Code
LOS MOLINAS, CA 96055800-892-3556
Date: Owner:
WORKERS' COMPENSATION DECLARATION
License #: 777334
I 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
Architect:
is issued.
❑ 1 have and will maintain workers' compensation insurance, as
Engineer: '
required by Section 3700 the Labor Code, for the performance of
the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier:_S�a. t e -ktnct
Total Square Ft: 0 S. F.
Policy #:_ D I 00 13 95 S
Valuation: $0.00
Census Code:
❑ 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 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
forthwithcomplywith those provisions.
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.
I Gx/�1
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
This. permit is hereb issued under the _-• pli ble pmvisions'ot the Butte County Code and/or
Resoluti ns to dp rk indicated abov for hich fees have
performance of the work for which this permit is issued (Sec 3097 Civ.)
Name:
been paid.
/1�.
Date: 0
Address:
PERMIT EXPIRES ON:
(Date)
❑ 1 hereby certify that the use of this facility shall comply with Sections 25505,
handling and use of hazardous materials.
25533, and 25534 of the California Health and Safety Code, which regulate the storage,
❑ Notification in accordance with Section 19827.5 of California Health & Safety Code is not applicable to the scheduled construction of this
❑ Attached are copies of the required E.P.A. notification forms.
project.
I hereby certify that I have read this application, that the above information is
all county and state laws relating to building construction. I acknowledge it is
correct, and that I am the owner or the duly authorized agent of the o /her. I agree to comply with
unlawful to alter th
u ce of any official form or. cument of Butte County. I hereby
authorize represen lives of quiteCountyto enter upon the above mentioned property for insp ction pure ses.
Print Name: hn �"�f GV
Signature
Date:
❑ Owner. ❑ Contractor
❑ Agent for Owner L7 Agent for Contractor
B. C. Building Permit 01-16-04 pg 1
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541
PERMIT NO.
BP061754
PERMITS BECOME NULL AND VOID 1 YEAR FROM THE DATE OF ISSUANCE, OR IF WORK IS DONE IN VIOLATION OF ANY COUNTY OR STATE LAWS,
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I licensed under Issued Date: 07/20/2006 APN: 078-330-038-000
provisions of Chapter -9 (commencing with Section 700000 ) of Division 3 of
the Business and Professions Code, and my license is in full force and
LicenseLicense Number:
se Class : i Zi> 7:T1223 Site Address: 26 EDGEMONT DR ORO
Date: (;� 11 Map Index:
' U � Contractor.
OWNER -BUILDER DECLARATION Description: CHANGE OUT HVAC UNIT
I hereby affirm under penalty of perjury that I am exempt from the
Contractors' State License Law for the following reason (Sec. 7031.5
Business and Professions Code: Any city or county which requires a Owner: M'ELVILLE, STUART
permit to construct, alter, improve, demolish, or repair any structure, prior
to its issuance, also requires the applicant for such permit to file a 26 EDGEMONT DR
signed statement that he or she is licensed pursuant to the provisions of OROVILLE CA
the Contractor's State License Law (Chapter 9 commencing with Section 95966
7000) of Division 3 of the Business and Professions Code) or that he or
she is exempt therefrom and the basis for the alleged exemption. Any (530) 774-4839
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):):
❑ 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 Applicant: GALLAGHER'S HEATING & AIR
Code: The Contractors' State License Law does not apply to an PO BOX 35
owner of. property who builds or improves thereon, and who does
such work himself or herself or through his or her own employees,
provided that such improvements are not intended or offered for LOS MOLINAS, CA 96055
sale. If however, the building or improvements are sold within one
year of completion, the owner -builder will have the burden of 800-892-3556
proving that he or she did not build or improve for the purpose of
sale.).
❑ 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 Contractor: GALLAGHER'S HEATING & AIR
not apply to an owner of property who builds or improves thereon, PO BOX 35
and why contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
❑ 1 am Exempt under Article 3 of the Business and Professions Code LOS MOLT NAS, CA 96055
800-892-3556
Date: Owner:
WORKERS' COMPENSATION DECLARATION License M 777334
I hereby affirm under penalty of perjury one of the following declarations:
O 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 Architect:
is issued, Engineer:
O 1 have and will maintain workers' compensation insurance, as
required by Section 3700 the Labor Code, for the performance of
the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier: Total Ali e �-(,( i'1 _ Total Square Ft: 0 S. F.
Policy #:_-I 13 - 00 13 T5 S Valuation: $0.00
Census Code:
❑ . 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 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.
Date: I 6`� I oce
Applicant:
WARNING: Failure to secure workers' compensation coverage is
L
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.
As& r4 f
CONSTRUCTION LENDING AGENCY — -This permit is hereb issued under the pli ble provisions'of the Butte County Code and/or
I hereby affirm that there is a construction lending agency for the Resoluti hs to d rk indicated abov for hich fees have been paid.
performance of the work for which this permit is issued (Sec 3097 Civ.)
Name: By: o
Date:
Address: PERMIT EXPIRES ON:
(Date
O 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.
O Notification in accordance with Section 19827.5 of California Health & Safety Code is not applicable to the scheduled construction of this project.
O 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 ov/her. I agree to comply with
all county and state laws relating to building construction. I acknowledge it is unlawful to alter th u ce of any official form or. current of Butte County. I hereby
authorize represen tivetss of Butte County to enter upon the above mentioned property for insp tion purp ses.
Print Name: rim
�� �r(J�'
Signature•
Date:
❑ Owner ❑ Contractor ❑ Agent for Owner
Y L7 Agent for Contractor
B. C. Building Permit ni-in_ne ,
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATION
AND SUBMITTAL REQUIREMENTS
24 HOUR INSPECTION#: OROVILLE: (530) 538-7636 • CHICO: (530) 891-2834
OFFICE C (530) 538-7541
A FEE WILL BE REQUIRED AT TIME OFAPPLICA TION
Website: www.buttecounty.net/dds
"PLEASE PRINT CLEARLY"
. OWNER INFORMATION
Last Namee • 1 �
first meaav—�
Address Ed m0 ni D r
Cityfro v i l L e.
ate CFk
zip 5 9
Phone r'1 i I g [a
x
EF
E-mail
CONTRACTOR
Name
Addresgfb f4
City
StattA
Zi1cf&05G
Phonal r `i 1 -4 LA t -t l
'
Fax
E-mail
Lic. #_).1,
Class
APPLICANT SIGNATURE
X
For office use only:
ARCHITECT/ENGINEER
Name
j_ „ _S HVAC
Address
Z
City
/
Ll
State
Zip
Phone
Map Book
Fax
E-mail
Planner.
State License Number
APPLICANT SIGNATURE
X
For office use only:
APPLICANT INFORMATION
Name al
j_ „ _S HVAC
Address
Z
City
/
Ll
StateCA
Zi
Phone
Map Book
Fax
E-mail
Planner.
APPLICANT SIGNATURE
X
For office use only:
Zoning
Prop dress 1�
Flood Zone
ISRAI
WORKER'S COMPENSATION
Yes
I - No
Occ.
Type Const.
Subdivision Name
Map Book
Page
Lot #
Planner.
Date Approved:
OVER FOR SUBMITTAL REQUIREMENTS
PERMIT
NO
J
P
BIN #
PROJECT LOCATION
y Bldg
Prop dress 1�
Tdry v t
Cross Street
WORKER'S COMPENSATION
Policy Number
-11 - O o t -�) 3 55
Carrier t-wc fw f i[ r
If hiring anyone other than license contractors, a certificate of worker's
compensation must be shown at the time of permit issuance.
LENDING AGENCY
Name
Address
Description or Scope of Work:
o of N -v R C u(ml
Sq FT- Living Garage Open Cov
❑ 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: Amount:
y Bldg
�1
SRA
Receipt #:
Sheriff
SMIP
Date: 6
Other
Total
K:IFORMS\BUILDINa FORMS1BldgApplSubRgmts.doc Page 1 of 2
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