HomeMy WebLinkAboutB21-1736 PERMIT ISSUANCE FORMS - SIGNED7/8/2021 Submission Completed
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Building Permit Intake Forms
Permit Information and Form(s) Selection
Permit Number *
APN*
Property Address
Permit Type
Permit SubType
Permit Description
Property Owner
Applicant Email *
Select Required Forms*
Contractor or Owner*
B21-1736
010-200-032
201 WASHINGTON ST
MISCELLANEOUS
FIRE SUPPRESSION-COM
SPARK DETECTION SYSTEM
TWIGG & PEGGY FAMILY TRUST
CALDWELL
GMACOMBER@ffprotection.com
ISSUE PERMIT
FIRE RESIDENTIAL BUILDING REQUIREMENTS
NPDES (<1 Acre)
NPDES (>1 Acre)
NOTICE TO BUILDERS
NOTICE TO BUILDERS FOR OVER-THE-COUNTER
PW - 26.12
Environmental Health
North Chico Flood Disc
Camp Fire Donation
Camp Fire Notice
Contractor Owner Owner/Builder
7/8/2021 Submission Completed
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Licensed Contractor's Declaration
Contractor (Name)
State Contractors
License No.
Class
License Expiration
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.
FOOTHILL FIRE PROTECTION INC
783132
C16
08/31/2022
7/8/2021 Submission Completed
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Workers' Compensation Declaration
I HEREBY AFFIRM UNDER PENALTY OF PERJURY one of the following declarations:
Carrier
Policy Number
Expiration
WARNING: FAILURE TO SECURE WORKERS’ COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO 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 have and will maintain a certificate of consent to self-insure for workers’
compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I have and will maintain workers’ compensation insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is
issued. My workers’ compensation insurance carrier and policy number are:
ZURICH AMERICAN INSURANCE COMPANY
WC5513774
10/01/2021
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 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.
7/8/2021 Submission Completed
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Permit Application Declaration
I am (choose one):
By my signature, I certify to each of the following:
I have read this construction permit application and the information I have provided is correct.
I agree to comply with all applicable city and county ordinances and state laws relating to building construction.
I authorize representatives of this city or county to enter the above-identified property for inspection purposes.
I understand approved plans with butte county stamp must be present on the job site for ALL inspections. If your
plans are digital, please print the approved set with our stamp for the job site. If you have questions, contact the Permit
Center prior to scheduling an inspection.
A California licensed contractor
The property owner
Authorized to act on the property owner’s behalf
7/8/2021 Submission Completed
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Final Page
By signing here I agree and understand the forms that have been provided to me above:
Signature*