HomeMy WebLinkAbout079-250-010IOL
0
WILLIAM STRACHAN
-621,_P.inecrest Dr ._, V
Oroville -- —01 0 � �t
- f i � a LJ lJ _
Permit#3552-86B(reroof/SF)
' •PERMIT#95-301 _.
STRACHAN, William' A;1_1 /t.
2621 Pinecrest Dr., Oroville�IY1 X'.
Misc Ele/SF I) 1
�i 97-1667 B.,E
STRACHAN, William. 4
2621 Pinecrest Roa.d,'ORoville
(repair wiring & misq e e rep)SF II"'
BP040673
DUTTON, KATHERINE E. ,
2621 PINECREST RD. OROVILLE
REMODEL �(_ �I+"QO
Q7M �-�e-a5
00
D
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Permit#3552-86
Wm Strachan
2621 Pinecrest Dr
0
COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS
_ 7 County Center Drive - Oroville, California 95965 - Telephone 916/534-4541
APPLICATION AND PERMIT
—PERMIT NO.
ASES OR PARCV- UMM Fjn A
(/,1( U piJ
ZONING
BUILDING PERMIT
OWN R t
f �G
TELEPHONE
SQ. FT. OCC. BUILDING VALUATION
OWNER' MAILING ADD SS
T." h e r k16 j'llr-
•COn A O •5 NA TE EPHONE
CO T C OR•S MAILING ADDRESS
Fireplace
CONSTRUCTION LENDER
UNKNOWN
Total Valuation $
LENDER'S MAILING ADDRESS
Filing Fee
$ 10.00
Permit Fee
$
ARCHITECT OR ENGINEER
LICENSE NO.
Plan Checking Fee
$
Energy Plan Checking Fee
$
ARCHITECT OR ENGINEER'S MAILING ADDRESS
Penalty
$
BUILDING ADDRESS /
Permit fee
$ .1190
PLUMBING PERMIT
Filing Fee 10.00
Each Trap
2,00
rej
Solar or heat pump water heater
20.00
LOT NO.
SUBDIVISION NAME PARCEL MAP
Water piping
5,00
Each etas water heater or vent
5,00
USE OF STRUCTURE
SF Duplex❑ Mobilehome❑ Other
SPECIFY
Gas piping system 1 - 5 outlets
5.00
Building sewer
5.00
Mobile Home S G W
10.00 en
TYPE OF WORK
New❑ Addition[:]model Utilities Installation[]Other
Describe work: re W1
Permit Fee
$
Contractor
ELECTRICAL PERMIT
Filing Fee 110.00
Main service 600V OR LESS
100 AMP OR LESS
10.00
Main service EA. ADD'L 100 AMP
2.50
CONTRACTORS LICENSE LAW
I declare under penalty of perjury (check one):
❑ I am licensed under provisions of Chapt. 9, Div. 3 of the BUSIneS$
and Professions Code and my license is in full force and effect.
License No. Classification
I, as the owner, or my employees with wages as their sole compen-
sation, will do the work,and the structure is not intended or offered
for sale. (Sec. 7044)
ElI, as the owner, am exclusively contracting with licensed contract -
ors. (Sec. 7044)
❑ I am exempt under Sec. , Business and Professions Code
for this reason
CONACCST
GOCCUP.&) S. yzQsgft
OR ADDNST
NEW CONSTR ULTI-OUTLET
...RE
ED BRANCH CIRC ITS 2.50 ea
NSI
POWER APPARATUS &)
SINGLE OUTLET CIR.
z0®D0e
Ex. Occup(OUTLETS OR FIXTURES 5AL030
FIXED APPLNS. OR
EX. Occup. OUTLETS (RESID.) EA.) 2.00
Temporary service 10.00
Mobile Home Facilities 15.00
Misc. Wiring 15.00
Permit Fee $
WORKMEN'S COMPENSATION INSURANCE
I declare under penalty of perjury (check one):
❑ The permit is for $100.00 (valuation) or less.
❑ I have placed on file with the County of Butte Building Department
a Certificate of Workmen's Compensation Insurance or a Certificate
of Consent to Self -Insure.
I shall not employ any person in any manner so as to become subject
to the W. C. laws of California.
Notice to Applicant: If after making this statement, should you become subject
to the W. C. provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
Contractor
MECHANICAL PERMIT
Filing Fee 10.00
Heating
Conlin g
Hood
3,00
Ventilation
Permit Fee
$
Contractor
I certify that I have read this application and state that the above information
is correct. I agree to comply to all County Ordinances and State Laws relating
to building construction, and hereby authorize representatives of the Countyot
Butte to enter upon the above-mentioned property for inspection purposes.
I also agree to save, indemnify and keep harmless the County of Butte against
all liabilities, judgments, costs, and expenses which may in any way accrue
against said County I cons quence of the granting of this permit.
X /Y�y Z�
Date
Signature of Applicant — Owner Contractor ❑ Agent ❑
An OSHA permit is required for excavations over 5'0" deep and demolition or construct-
ion of structures over 3 stories irl height.
Mobile Home Installation Fee $
Energy Inspection Fee $
TOTAL PERMIT FEE
Occup,
CONST*TYPEJ
FLOOD
PARCEL
I PD
MD
IS9UE
This permit is hereby issued under
sions of the Butte County Code and/or
work indi ted above for which
DIRE OF PU
B rle
PERMIT EXPIRES Date
the applicable provi-
resolutions to do
fees have been paid.
I rWORKS
D 4ee/ S
�/.J^
Receipt No. Q1118111,
WNITE-D.P.W., YELLOW-ASSCS30R, PINK -INSPECTOR, GOLDENROD -APPLICANT
COUNTY'OF BUTTE - Department of Public Works
7 County Center Drive, Oroville, CA 95965 Phone: 916-534-4541
OWNER -BUILDER VERIFICATION
Attention Property Owner:
An 'owner -builder" building permit has been applied for in your name and bearing
your signature.
Please complete and return this information at your earliest opportunity to avoid
unnecessary 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 aterials for construction of
the proposed property improvement (yes or no) .
2. I (have/have not) signed an application for a building permit
for the proposed work.
3. I have contracted with the following person (firm) to provide the proposed
construction:
Name
Address City
Phone Contractors License No.
4. I plan to provide portions of this work, but I have hired the following person
to coordinate, supervise, and provide the major work:
Name
Address City
Phone Contractors License No.
5. I will provide some of the work but I have contracted (hired) the following
persons to provide_ the work indicated:
Name . Address Phone Type of Work
Signed:
- Property Owner Z2
„
Social Securi y Number
Date z
NOTE: This Owner -Builder Verification is sent to you as required by Sections 19831 and
19832 of the California Health and Safety Code. ,
This verification must be completed and returned to our office before we are per-
mitted to issue the permit.
3
William Strachan
2601 Pinecrest Dr.
Oroville, CA 95965
Dear Mr. Strachan:
November 19, 1986
RE: Building Permit
A.P. #36-30-24
With reference to the above subject, we have. been advised by one of our
building inspectors that you have not obtained the required permits and
inspections from this office for the work you are doing as follows:
Reroofing the residence at 2621 Pinecrest Dr.
Since permits and inspections are required by both State and County laws,
please contact this office within ten days of the date of. this letter, apply
for the required permits, and pay the appropriate fees.
All work must stop until you obtain these permits and .are authorized by
our field inspector to proceed. This field authorization, cannot be made
until the existing work is inspected and approved.
Your cooperation in resolving this matter would certainly be appreciated.
Should you have any questions concerning this matter, please contact this
office.
JFG:ahb
ccs Building Inspector - Oroville
Assessor
Yours very truly,
William Cheff
Director of Public Works
Original sigrn@A by
J. F. Glandes
J.F. Glander
Chief Building Inspector
❑ Com�.aint-Date
[] Other -Date
BUTTE COUNTY DEPARTMENT OF PUBLIC WORKS
SPECIAL INSPECTION REPORT
ZONING
76 = '1 `.0 l
Owner: i'JV�YYI' g 1- �L? A. P.
Address:Date of Inspection
Tenant:_
Inspector
Building Location C CQ 't')l h P 0, Y- 2
Type of Inspection requested:
Housing / / 2. Financing /_/ 3. Change of Occupancy to
f 4. Work W/0 Permit / / 5. Other, (specify) '
Present use of building:
A. Sanitation (Housing)
1. Water closet:
2. Lavatory:
B.
C.
3. Bathtub or shower:
4. Kitchen sink:
5. Hot and cold water to fixtures:
6. Heating facilities:
7. Natural light and ventilation:
8. Room and space requirements:
9. Bedroom window or door for second exit:
.10. Infestation of insects, vermin, or rodents:
11. Connection to sewage disposal:
12. Connection'to water supply:
13. Rubbish and garbage facilities:
14. Stairs:(Rise, Run, Headroom, 1HR, Tolerance$,Handrails)
15. Comments:
Structural
1. Piers and footings:
2. Floor construction:
3. Wall construction:
4. Ceiling and roof construction:
5. Fireplaces:
6. Comments:
Electrical
1. Service and ground:
2. Receptacles:
3. Fusing:
4. Comments:
D. Plumbing
1. Fixtures connected and vented:
2. Gas water heater:
3. Gas heating vents:
-4. Comments:
E. Other
1. Maintenance and repair:
2. Fire hazards:
3. Safety hazards:
4. Weather protection:
5. Underfloor and attic ventilation:
6. Energy:.
7. Comments:
F. Commercial Buildings
1. Roof covering:
2. Distance to property lines:
3. Physically handicapped: _
4. Restroom floors and walls:
5. Exits:
6. Improvements:
7. Zoning:
8. Comments:
G. Field Problems or Violations
1. Problem or violation (give complete description): RQ--Vg�� jA) & MTI1 s
2. What actin taken (give complete descr' (1l►on):
- I) L&:) ng -4r- =rid 1 s I v o 6 S tea)
3. What action recommended:
A. Information only - file.
B. Hold for ten days, then write letter.
C. Write letter.
/
/.D. Other:
--036-300-102 PERMIT#95-3011
-STRACHAN William
2,621 Pinecrest Dr.-, Oroville
Misc Ele/SF ti
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OFFICE COPY:.-
Address
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COUNTY OF BUTTE -DEPARTMENT OF DEVELOPMENT SERVICES -BUILDING
7 County Center Drive - Oroville, California 95965 - Telephone (916) 5PERMIT NO.
APPLICATION AND PERMIT
ASSESSOR PARCEL NUMBER 036-300-102
"XM*12.5
BUILD G PERMIT
OWNER WILLIAM STRACHAN.
TELEPHONE
SO. FT. OCC. BUILDING VALUATION
OWNERS MAILING ADDRESS 2601 PINECREST RD OROVILLE, 95966
CONTRACTOR'S NAME OWNERTELEPHONE
CONTRACTORS MAILING ADDRESS
Fireplace
CONSTRUCTION LENDER
UNMOWN
Total Valuation Is
LENDER'S MAIUNG ADDRESS
Filing Fee
$ 20,00
Permit Fee
$
ARCHITECT OR ENGINEER
LICENSE NO.
Plan Checking Fee
$
ARCHITECT OR ENGINEERS MAILING ADDRESS
Energy Plan Checking Fee
$
Penalty
$
BUILDINGADDRESS
2021 PIidECREST RD
PERMITFEE
$
OROVILLE
PLUMBING PERMIT
Filing Fee 20.00
Each Trap
7.00
LAT NO.
SUBDIVISION'S NAME
PARCEL MAP
Solar or heat pump water heater
23.00
USE OF STRUCTURE
SF ❑X Duplex ❑ Mobilehome ❑ Other
SPECIFY__
Water piping
15.00
Each gas water heater or vent
15.00
Gas piping system 1 - 5 outlets
15.00
Building sewer
15.00
TYPE OF WORK
New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other di REPAIR
Describe Work: REPAIR WIRING -2 MAIN SERVICE BETIJEEN
}
MAIN SERVICE PANEL & WEATHERHEAD.
Mobile Home IS I GI W
@20.00
PERMITFEE
S
Contractor
ELECTRICAL PERMIT
Filina Fee 20:00
Main Service000V OR'Ess
( zooA oR LEss )
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:
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.
❑ 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.
OR ADDNS. ( 8 ACC. BUDS. )
SO.
3.50 FT.
NEW CONST. MULTI.OUTLET
NON-RESIO. ( BRANCH CIRCUITS )
@7.50
POWER APPARATUS
(a SINGLE OUTLET CIA. )
EX. Occup. (OUTLET OR FIXTURES )
20 @ 1.00
BAl SO
FIXED S.
EX. Occup. OUTLETS (RESID.)
( )
5.00
Temporary Service
23.00
Mobile Home Facilities
20.00
Misc. Wiring
23.00
PERMITFEE
$ 43.00
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
Cooling
Hood
6.50
Ventilation
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 wi h those provisions.
X� • r Date
Signature of Applicant - wne 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 Is
occ
CONST. TYPE
I
TOTAL FEE $
HAZ.
1 D. FEES
I IMP
I FLOOD
CDF PARCEL PD HD
ISSUE
This permit is hereby issued under the applicable provisions
of the Butte County Code and/or Resolutions to do work
indicated above for which fees have been paid.
i _ p�
BY Date 141,
PERMITEXPIRESON % ` 7 to
(Date)
Receipt No.CN O U
WHITE-D.D.S.-B.D. I CANA -ASSESSOR PINK -INSPECTOR GOLDENROD -APPLICANT
Attention Property Owner:
An "owner -builder" building permit has been applied for in your name and bearing your
signature.
Please complete and return this information at your earliest opportunity to avoid
unnecessary 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 " NO[ ].
2. I HAVE[y] HAVE NOT[ ] sighed an application for a building permit for the
proposed -%ro-&
3. I have contracted with the following person (firm) to provide the nronosed
construction:
NAME:
ADDRESS: CITY:
PHONE: 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.
5. I will provide some of the work but I have contracted (hired) the following persons to
provide'the work indicated:
NAME ADDRESS PHONE TYPE OF WORK
SIGNED:
PROPERTY OWNER:
SOCIAL SECURITY NUMBER:
DATE:
NOTE: This owner -Builder Verification is required by Section 19831 and
19832 of the California Health and Safety Code.
This verification must be completed and returned to our office before
we are permitted to issue the permit.
.L
OVER
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036-30-0-102 97-1667 B,E
STRACHAN, William
2621 Pinecrest Road, ORovill'e
# (repair wiring & misc ele rep)Sk'
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036-30-0-102 97-1667 B,E
STRACHAN, William
2621 Pinecrest Road, ORovill'e
# (repair wiring & misc ele rep)Sk'
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�s. 3011
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COUNTY OF BUTTE- DEPARTMENT OF DEVELOPMENT SERVICES- BUILDING DIVISION
7 County Center Drive - Oroville, California 95965 - Telephone -(916) 538-7541 PERMIT No.
(Rev. 12/96) APPLICATION AND PERMIT � Z�/
ASSESSOR PARCEL NUMBER
—100-107
zONr G
ARW7 5
•BUILDING PERMIT
OWNER
T M A
TELEPHONE
SO, FT. OCC. BUILDING VALUATION
—COM
500
OWNERS MAILING ADDRESS
7nuni PTVV •17cA oso66
CONTRACTOR'S NAME
TELEPHONE '
CONTRACTORS MAILING ADDRESS
CONSTRUCTION LENDER. f
Fireplace
LENDER'S MAILING ADDRESS `
'
Total Valuation $
Filing Fee
$ 20.00
ARCHITECT OR ENGINEER • �� s -w ,.....c
NF
LICENSE NO.
Permit Fee
$1.5-00
ARCHITECT OR ENGINEERS MAILING ADDRESS
'-N r _ \ -
Plan Checking Fee
$
BUILDING ADDRESS "-
_
F T.
Energy Plan Checking Fee
$
PERMIT FEE
$ 35.
LOT NO.
SUBDIVISIONS NAME
PARCEL MAP
PLUMBING PERMIT
Fling Fee 20.00
USEOFSTRUCTURE
SF .j& Duplex ❑ Mobilehome ❑ Other
SPECIFY
Each Trap
7.00
-
Solar or heat pumpwater heater
23.00
Water piping
15.00
Each gas water heater or vent
15.00
TYPE OF WORK
New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other 19
Describe Work: REPAIR WIRING RE: BP 95-3011 AND
MISC REPAIRS
Gas piping system 1 - 5 outlets
15.00
Building sewer
15.00
Mobile Home Is I G W1
@20.00
PERMIT FEE
$
ELECTRICAL PERMIT
Filing Fee 20.00
800RMain Service 200, 00 R LESS
23.00
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
L w 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
Main Service 200A TO 1000A
46.00
NEW CONST. DWELLING OCCUR
OR ADDNS. ( a ACC. BLDS.
s0
3.5¢FT;
NON-RNE -ES DONST MULTI-O RCUI TS
@7.50
POWER APPARATUS
b SINGLE OUTLET CIR.
Ex. Occup. OUTLET OR FIXTURES
zp I. @ .550
BAL 0
P
Ex. Occup. OF�IxTLE�DSRE In.) E
5.0 0
Temporary Service
23.00
Mobile Home Facilities
20.00
Misc. Wiring
23.00 23,00
PERMIT FEE
S 43 .00
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
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 with those provisions.
�J/ y
X�-- Date / _—
Signature of -Applicant - ❑ wner ontractor ❑ Agent
An OSHA permit is required for excavations over 60" deep and demolition or construction
of structures over 3 stories in height.
MECHANICAL PERMIT
Fling Fee 20.00
Heating
Cooling
Hood 6.50
Ventilation
PERMIT FEE $
Mobile Home Installation Fee $
Energy Inspection Fee $
OCC
CONST. TYPE
TOTAL FEE $ 78
HA2.
D. FEES
IMP
FLOOD
CDF
PARCEL
PD
HDI ISSUE
This permit is hereby issued under
of the Butte County Code and/or
indicated above for which fees have
J
By �!� , , .--•----
PERMIT EXPIRES ON
the applicable provisions
Resolutions to do work
been paid.
Date
'70"t
Receipt No. :2_2( I Z/L
WHITE-D.D.S.-B.D. CANARY -ASSESSOR PINK -INSPECTOR GOLDENROD -APPLICANT
COUNTY OF BUTTE- DEPARTMENT OF DEVELOPMENT SERVICES - BUILDING DIVISION
7 CountyCenter Drivo - Oroville, California 95965 - Telephone (916) 538-754/ ti2�1
0.
(Rev. 12/96) APPLICATION AND PERMIT a
ASSESSOR PARCEL NUMBER
036-300-102
ZONING
ARMH2.5
BUILDING PERMIT
OWNER
WILLIAM STRACHAN
TELEPHONE
SO, FT, OCC. BUILDING VALUATION
CONTR
500
OWNER'S MAIUNG ADDRESS
CONTRACTOR'S NAME
OWNER
TELEPHONE '
CONTRACTOR'S MAILING ADDRESS
CONSTRUCTION LENDER
NONE
LENDER'S MAIUNG ADDRESS
Fireplace
Total Valuation $
ARCHITECT OR ENGINEER
NONR
LICENSE NO.
—Filing F@@
$ 20.00
Permit Fee
$ 15.00
ARCHITECT OR ENGINEERS MAILING ADDRESS
Plan Checking Fee
$
BUILDING ADDRESS
9691 PINFICREST Rn- 0ROVITLE
Energy Plan Checking Fee
$
$
PERMIT FEE
$ 35.00
LOT NO.
SUBDIVISION'S NAME
PARCEL MAP
PLUMBING PERMIT
Filing Fee 20.00
USEOFSTRUCTURE
SF R Duplex ❑ Mobilehome ❑ Other
SPECIFY
Each Trap
7.00
Solar or heat pump water heater
23.00
Water piping
15.00
Each gas water heater or vent
15.00
TYPE OF WORK
New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other Co
Describe Work: REPAIR WIRING RE: BP 95-3011 AND
MISC REPAIRS
Gas piping system t - 5 outlets
15.00
Building sewer
15.00
Mobile Home I S I G I W
@20.00
PERMIT FEE
$
ELECTRICAL PERMIT
Fling Fee 20.00
a00V ORLESS
Main Service zo.AORLESs
23.00
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that 1 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
I hereby affirm under penalty of perjury that I am exempt from the Contractors License
Lfor the following reason:
N 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
Main Service 200A TO 1000A
46.00
NEW CONST. DWELLING OCCUP.
OR AODNS. ( a ACc. BLDs.
SO
3.5¢FT.
NEW
NON -R S11DT S.M JLCTI.OUTLET
@7.50
8 POWER APPARATUS
SINGE OUTLET CIR.
Ex. Occup. OUTLET OR FIXTURES
20 @ ''50
SAL p .so
Ex. Occup. ouxT rs RELNSIo.OEA.
5.00
Temporary Service
23.00
Mobile Home Facilities
20.00
Misc. Wiring
23.00 23.00
PERMIT FEE
$ 43.00
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
Cooling
Hood
6.50
Ventilation
PERMIT FEE
$
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 yfith those provisions.
,e:� '� _4�
Date
re of A Ilicant - ❑ r ❑ Contrac__ tor ❑ Agent TT
Signatucane
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 $
occ
CONST. TYPE
TOTAL FEE $ 78.00
HAZ.
I D. FES IMP
I FLOOD
I COF
I PARCEL
I PD
TWI
ISSUE
This permit is hereby issued under
of the Butte County Code and/or
indicated above for which fees have
By
PERMIT EXPIRES ON
the applicable provisions
Resolutions to do work
been paid.
Date V _
Dafe
ReceiptNo. 2Zy�2—
WHITE-D.D.S.-B.D. CANARY -ASSESSOR PINK -INSPECTOR GOLDENROD -APPLICANT
OWNER -BUILDER VERIFICATION
Attention Property Owner:
An '`owner -builder" building permit has been applied for in your name and bearing your signature.
Please complete and return this information at your earliest opportunity to avoid unnecessary 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, NO ❑
2. I HAVE 4d-- HAVE NOT ❑ signed an application for a building permit for the proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction:
NAME:
ADDRESS: CITY:
PHONE: 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.
5. I will provide some of the work but I have contracted (hired) the following persons to provide
the work indicated:
NAME ADDRESS PHONE TYPE OF WORK
,/'SIGNED: 1.
l(>C PROPERTYOWNER:
SOCIAL SECURITY NUMBER;
DATE: �'- -- 7 't? 7
NOTE. This Owner -Builder Verification is required by Section 198.31 and 19832 of the
California Health and Safety Code. This verification must be completed and
returned to our office before we are permitted to issue the permit.
OVER
OWNER BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of property
improvements specified.
For your protection, you should be aware that as "owner -builder" you are the responsible party of record on such
a permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business
license from the city or county. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should
be aware of the following information for your benefit and protection:
♦
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is 5300 i:* -mcre. for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
♦ If you are an employer, you must register with the State and Federal Governments as an employer and you are
subject to several obligations including state and federal income tax withholding, federal social security taxes,
workers compensation insurance, disability insurance costs, and unemployment compensation contributions.
♦ There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious
with respect to worker's compensation insurance.
♦ For more specific information aboutyour obligations under Federal Law, contract the Internal Revenue Service (and,
if you wish, the U.S. Small Business Administration). For more specific information about your obligations under
State Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "owner builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building
permits are not required to be signed by property owners unless they are performing their own work personally.
Information about licensed contractors may be obtained by contracting the Contractors State License Board in your
community or at 1030 N Street, Sacramento, CA. 95814.
Please complete the "Owner Builder Verification" on the reverse side of this form so that we can confirm that you
are aware of these matters. The building permit will not be issued until the verification is returned.
c t rely,
Mic el C. Vi ira, C.B.O.
M ger, Building Inspection
NOTE. This Oivner-Builder Information is required by Section 19830 of Ilse California Health and Safety Code
OVER
NOTES , i --
N
RESIDENTIAL
PERMIT NO. 036-300-102 BP040673
DUTTON KATHERINE E. -
2621 PINECREST RD., OROVILLE
REMODEL
SPECIAL CONDITIONS
SRA
FLOOD CERTIFICATE REQ.
FIRE SPRINKLERS REQ.
SPECIAL INSPECTION ITEMS
VERIFY
USE PERMIT CONDITIONS
SUB -STANDARD HOUSING LETTER
/v - ZF-cv wr
OFFICE COPY
Ldds
DateBy
TRIC Date
By
,JOB FINALED (Date)
Signature �
� h.
CHECKED
BY
i"
I .
i
N
RESIDENTIAL
PERMIT NO. 036-300-102 BP040673
DUTTON KATHERINE E. -
2621 PINECREST RD., OROVILLE
REMODEL
SPECIAL CONDITIONS
SRA
FLOOD CERTIFICATE REQ.
FIRE SPRINKLERS REQ.
SPECIAL INSPECTION ITEMS
VERIFY
USE PERMIT CONDITIONS
SUB -STANDARD HOUSING LETTER
/v - ZF-cv wr
OFFICE COPY
Ldds
DateBy
TRIC Date
By
,JOB FINALED (Date)
Signature �
� h.
CHECKED
BY
J=OK
0 = Not OK
= Not Applicable
. = Not Ready
RESIDENTIAL (Single & Duplex)
Date UNDERFLOOR (Plans) OK except #'s
1. Zoning -Setbacks -Easements -Flood -Slope
2.
Ftg., Main; Soils-Elec. Grnd.-/ /" Ftg. Depth
3.
Ftg., Garage; Soils-Steel-Elec. Grnd.-/ /" Ftg. Depth
4.
Ftg., Porches & Decks; Soils -Steel-/ /" Ftg. Depth
5.
Stemwalls, Main; Steel- Bloc kouts-Wrapped
6.
Stemwalls, Garage; Steel- Bloc kouts-Wrapped
6a.
Hold Downs and Special Anchors
7.
Slab, Steel -Wrapped
8.
Piers -Fireplace Ftg.-Steel
9.
D.W.V.; Fall -Fitting -Test -2 Way C/O -Sewer Test
10.
UF, Gas Pipe; Size Anchors -Yard Gas Piping; Size Test
11.
Water Pipe; Test -Anchors -Regulator -Service Test
12.
Electric Underground
13.
Plenums & Ducts; Clearance -Material -Support -Ins.
14.
Girders -Sills -Anchor Bolts-Joists-Vents-Crippies
15.
Access & Ventilation
16.
Insulation
Date
47.
Card B-1 Date Card B-1
Date
Joist-Rftr. Ties- Purlin-Roll Brac.-Truss-Shting.-Rtng.
Fireplace Ties or Type A Flue -Fireplace Throat Clearance
Attic Access; Size & Romex Protection -Draft Stop -Ins. Baffles
Card B-1 Date Card B-1
Date
PLUMBING (Permit) OK except #'s
17. Water Htr.; Vent -Access -Combustion Air Baffle
Water Pipe; Test & Anchor -Nail Protection
53.
1
20.
D.W.V.; Test Fittings & Anchor -Nail Protection
Shower Pan; Test, First Floor -Tub Access
Ext. Doors -One 3' -Check Garage 3rd Story, 2 Exits
21.
Test Tub & Shower, Second Floor -Tub Access
56.
22.
Gas Pipe; Sixe & Anchors
Siding -Nailing Veneer
23.
Fire Sprinkler; Test
59.
Glazing Area -Glass Protection -Skylights -Plastic
60.
Date
61.
Card B-1 Date Card B-1
Date
-uufation-Walls-Ceilings
Infiltration -Walls -Windows
Card B-1 Date Card B-1
Card B-1 Date Card B-1
Date
ELECTRICAL (Permit) OK except #'s
(Plans) OK except #'s
24.
Fixture & Transformer Clearance -Ins. Protection
rK
25.
Elec. Receptacles Spacing -Lights & Switches at Doors
urnace Vents -clearance -Comb, Air-Connector-
In,G5raae: Above Floor-Ducts-Mech. Protection
26 a Boxes & No. of Conductors Stapled
Amex Installed Close to Edge of Studs & C.J.
28. Equip. Ground made up w/Mech Fasteners -Bond Gas & Water
29. 2 Appliance Circuits in Kitchen & Conductor Size GFI
30.
Subfeed Wire Size/ /ga. Cu or AI-A.C. Wire Size/ /ga Cu or Al
31.
Range Circle/ /ga Cu or AI -Oven Circ. / /ga Cu or Al
Insulated Neutral O Yes O No
32.
Service -Riser Conductors & Ground Main Disconnect
33.
Equip. Clearances Panels-Motors-Mech. Equip.
34.
Clothes Closet Light -Shower Light -Spa Light
35.
Smoke Detector
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
MECHANICAL (Permit) OK except #'s
36.
A.C. Ducts Insulation & Support
37.
Vent Fan, Exhaust above insulation
38.
Condensate Drain & Overflow, Size & Grade
39.
Furnace -Vent Access -Comb. Ait-Return Air Vent 115 Outlet
40.
Attic Access & Platform if Furnace in Attic
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
FRAMING (Permit) OK except #'s
41.
Sills Proper Materials & Anchors
42.
Walls Studs -Nailing Spacing & Braces -Plates -Sound
43.
Bearing Walls over Girders & Floor Nailing
44.
Draft Stop in Walls (rat proof)
45.
Fire Stops, Furred Ceilings -Stairs -Chasers -Tubs
46.
Headers & Beams -Size & Bearing
Date FRAMING (Continued)
47.
Ha ers-Post Caps -Anchors -Connectors
atizem 4aoMng.
9.
50.
Joist-Rftr. Ties- Purlin-Roll Brac.-Truss-Shting.-Rtng.
Fireplace Ties or Type A Flue -Fireplace Throat Clearance
Attic Access; Size & Romex Protection -Draft Stop -Ins. Baffles
51.
Bdrm. Windows or Exiting Doors -Sill Ht. & Dimensions
52.
Garage Fire Protection Framing -RC Channel
53.
Property Line Firewall & Openings
54.
Ext. Doors -One 3' -Check Garage 3rd Story, 2 Exits
55.
Stairs; Width -Headroom -Rise -Run -Landing -Fire Protection
56.
Plywood on Roof Overhang -Attic Vents -Rafter Outriggers
57.
Siding -Nailing Veneer
58.
Stucco Mesh -Drip Screed -Fd. Vents-Underflr. Access
59.
Glazing Area -Glass Protection -Skylights -Plastic
60.
Shear Walls; Nailing -Bolts
61.
Brace Interior/Exterior Wall Panels
62
63.
Date
-uufation-Walls-Ceilings
Infiltration -Walls -Windows
Card B-1 Date Card B-1
Date
Car B-1 Date Card B-1
Date FI
(Plans) OK except #'s
4.
_Ext. Steps -Door & Sidelight Protection -Landings
rK
Smoke Detector
66
urnace Vents -clearance -Comb, Air-Connector-
In,G5raae: Above Floor-Ducts-Mech. Protection
68,,,-F.1. & Bath Fixtures & Tub Access -Spa
EleirTrim & Subpanel, Breaker Sizes & Labels
-?TFire Ip ace or Stove, Clearance -Hearth
�c!Outlets at Wood Panel, Int. & Ext.
7,3!Kit. Fixt. & Appliance; Ground -Air -Gap -Cooking Clearance
lec. Outlets & Receptacles at Kit. Counter
J.S. ge Fire Door; Swing -Landing -Closure
7V A.C. Duct in Garage -Damper
77. Wtr. Htr.; Vents -Clearance -Comb. Air Connector.-P.R.V.
Gar ge; Above Floor-Mech. Protection
Elec. & Mech. Equip. Listed for Location
79'. Ele Receptacles in Garage (F.F.I.)-Romex Protection
8 nsulation-Foam-Looked in Attic
81. Guard Rails & Deck Construction -Post Caps
rSTFdn. VBents & Crawl Hole Door Drainage & Wood -Earth
Clearance Looked under Floor O Yes
82 --Following Instld./Drive 0 Yes Cl No/Walks 0 Yes 0 No/Planters 0 Yes 0 No
-44-Stucco Brown -Finish
8YA.C. Unit Disconnect, Electrical -Plumbing
86. Vents Above Roof, Plbg-Appliance-Fireplace-Clearance to Openings
Water Well, Disconnect, Electrical, Plumbing
84. Exterior Elec. Trim, G.F.I. Receptacle -Underground
89. Yentilation Throughout House
9V Glass Protection
Corrections from Previous Inspections
Gas Test -Meters Tagged, Gas -Electric
X93: Water & Sewer Connected -C/O to Grade -HD Approval
nergy Compliance Certificate -Other Certificates
95. Address Posted
96. Fire Sprinkler
Date (gyp, Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
Date Card B-1 Date Card B-1
Comments at Final:
J=OK
0 = Not OK
Not
. NotReadyable
DECKS, COVERS, CARPORTS, GARAGES (Plans) OK except #'s
MOBILE HOMES
Date
MOBILE HOME UTILITIES (Plans) OK except #'s
1.
Zoning Requirements -Setbacks -Easements
2.
Soils; Special MH Support Sketch
3.
Sewer; Location -Test -Fall -C/O -Concrete
4.
Water; Location -Test -Easement Needed (Sketch)
5.
Electricity; Location-Clearances-Grnd-/ /Amp -Concrete
6.
Gas; Location -Test -Wrap;-/ /" L 'ft.
/ P Nat. or / /" L "ft./ P LPG
7.
Well Clearance & Disconnect
8.
Utility Clearance
10.
Roof; Shthg-Roofing
11.
Ext.; Steps -Doors -Landings
Date
12.
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
MOBILE HOME INSTALLATION (Plans) OK except #'s
Card B-1 Date Card B-1
1.
Zoning Requirements -Setbacks -Easements
Card B-1 Date Card B-1
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.
Tie Downs -Type -Installation Cert.
10.
Exits; Insp.-Sketch
11.
Cert. of Occupancy
10.
Plumb.; Cir. Test -Water Supply Test
11.
Light Niche
Date
12.
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
Date
PERMANENT END SYSTEM (ONLY)
Card B-1 Date Card B-1
1.
Zoning Requirements -Setbacks -Easements
Card B-1 Date Card B-1
2.
Footings; Size -Spacing -Marriage Line
3.
Blocking
4.
Gas; MH Test -Demand -Valve
5.
Electricity; MH Test
6.
Water; MH Test
7.
Water and Sewer Connected
8.
Gas and Electricity Tagged
9.
Exits
10.
License Decals
11.
Verify #'s with Office
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
1
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, Girders and/or Joists -Decking -Bracing -Stairs -Rails
4.
Wood Awn.; Posts-Beams-Rftrs-Connectors
Shthg-Frg-Bracing
5.
Alum. Awn.; Columns -Connections -Splice -Decal -Enclosures
6.
Carports; Windows -Doors
7.
Electric
8.
Frmg.; Sills-Anchors-Studs-Rftrs-Trusses
9.
Siding; Nailing -Veneer -Stucco -Mesh
10.
Roof; Shthg-Roofing
11.
Ext.; Steps -Doors -Landings
12.
Braced Wall Panels
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, Distance-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- Panel boards- Ins. to Main Conduit
9.
Health Department Approval
10.
Plumb.; Cir. Test -Water Supply Test
11.
Light Niche
12.
Enclosure; Fencing -Alarms
Date
Card B-1 Date Card B-1
Date
Card B-1 Date Card B-1
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #: (530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #: (530) 538-7541 FAX#: (530)538-2140
WEBSITE: www.buttecounty.netldds
PERMIT -NO.
BP040673
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: APN: 036-300-102-000
the Business and Professions Code, and my license is in full force and
effect. - ..._ .. - ... _ . . .. ....
11 - ...
License Class: License Number:
Site Address: 2621 PINECREST RD ORO
Date: Contractor:
Map Index:
Description: remodel (354)
OWNER -BUILDER DECLARATION
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
permit to construct, alter, improve, demolish, or repair any structure, prior
Owner: DUTTON KATHERINE E /
to its issuance,: also requires the applicant for such permit to file a
'statement
�.:";�; : N t.
45,8 NORD AVE #3
signedthat'he or she is licensed pursuant to the provisions of,
the Contractor's State License Law (Chapter 9 commencing`with Section'
' " CHICO, CA
7000) of Division 3•of the Business and Professions Code) or that he or'.
- 95926-4747
she^is exempt therefrom' and the basis for the alleged• exemption_ Any.
violation•of•Section 7031.5 by any applicaht fora -permit subjects the'
"
applicant to a civ Fkpenalty of not more than five hundred dollars ($500).):. _
!
` 1, a`s•owoer•of+the property,.or my employees with wages as their
y ^' „�"„-a...."�.•..,"~
sole compensation, will do the work, and the structure is not
intended or offered for saleSec. 7044, Business and Professions
" "Code:"The CorifracforVState L"ice'nse,Law does'not'-appiy•to an''
" Applicant: DUTTON KATHERINE E " -��• -~�'" • �' ���
owner of property who builds or improves thereon, and who does
_such work himself or herself or through his or her own employees,
that such improvements are not intended or offered for
.provided
" sale: If however, the building or improvements are sold within one
year of completion, the owner -builder will 'have the burden of
proving that he or she did not build or improve for the purpose of
sale.).
.p_owner,• of,,.the,•_property, ,am,-exclusivel,y,contr.actiRg,,.Witb
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,
Contractor:
,and who contracts for such projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
❑ a.m.,Exempt under Article 3 of three Business, and Professions Code
�
bate `Nt c4 e c � i � Owner:
License #:
,: �.• ° WORKERS' COMPENSATION DECLARATION
hereby
I affirm under penalty of penury 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.
Architect:
-13" 'I' hb' a anis 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:
Carver:
Total Square Ft: 0 S. F.
Policy#-
Valuation: $0.00
I certify that in- the performance of the work for which this permit is
Census Code:
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:- �j (G
"-APPlicantr- , /.,\..a ;CJ Lx ..• T 4 ,
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 ap_plicable provisions of the Butte County Code and/or
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec 3097 Civ.)
Resolutions to o rk ' di ted abov or which fees have been paid.
/::>I
Name:,.
BY Date: C)
PERMIT EXPIRES
Address:
ON.
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. j
O 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. 1
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 itis unlawful to alter the substance of any official form or document of Butte County. 1 hereby
authorize reprejseentatives of Butte County to enter up n the above mentioned property for inspection purposes.A. t
�e �,✓t-� ?
Print Name: �'l G4 c 1 /N Signature:
Date;. (M•ti� )0,0
Owner ❑ Contractor ❑ Agent for Owner ❑ Agent for Contractor
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BUTT --
BUILDING DIVISION
APPROVED
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