______________________________________________________________

PERMIT NUMBER: _________
CITY OF ALTURAS

BUILDING DEPARTMENT, 200 W. NORTH STREET

PHONE: 530-233-5232

FAX: 530-233-2799

EMAIL: building@cityofalturas.org

BUILDING PERMIT APPLICATION

____________________________________________________________
Building Address

__________________________________________________________
Assessor Parcel Number Zoning

_______________________________________________________________
Owner Telephone

_______________________________________________________________
Owner Mailing Address

_______________________________________________________________
Contractor Name Telephone

_______________________________________________________________
Contractor Mailing Address

_______________________________________________________________
Construction Lender Unknown

_______________________________________________________________
Lender Mailing Address

_______________________________________________________________
Architect or Engineer License Number

_______________________________________________________________
Architect or Engineer Mailing Address

_______________________________________________________________
City Business License Number License Number

_______________________________________________________________
Lot Number Subdivision Name Parcel Map

_______________________________________________________________

USE OF STRUCTURE

______Single Family ______Mobile Unit _______ Commercial

______Multiple Family ______ Other (Specify)________________________________________________

______________________________________________________________________________________

TYPE OF WORK

______New ______Remodel ______Installation

______Addition ______Utilities ______Other

Describe nature of work to be done:___________________________________________________________

________________________________________________________________________________________

Estimated Cost of: Materials________________, Labor_____________________

Dimensions:_________________ # of Bedrooms:_________ # of Baths:_________

Is there a dwelling/mobile home/guest house/other residence on the property now? Yes________ No________

Water Source: Public_____ Private Well_____ Other_____

Sewage Disposal Source: Public_____ Private Septic System____ Other______

Was there a previous application for sewage disposal? Yes_____ No _______

If yes, please give date:____________________________________________

FOR MOBILE HOME INSTALLATION ONLY:

Manufacturer:_________________________________Model:_____________________

Serial No. 1:_______________No. 2__________________No. 3___________________

State Insignia Number: Unit 1_______________ Unit 2_______________

Roof Live Load:_____________p.s.f. Wind Load____________p.s.f.

Year of Mobile Home:________ Date of Septic System permit_________

CONTRACTORS LICENSE LAW

I declare under penalty of perjury (check one):

_____ I am licensed under provision of Chapter 9, Division 3 of the Business and Professions Code and my license is in full force and effect.

_____ I, as the owner, 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)

____ I, as the owner, am unexclusively contracting with licensed contractors. (Sec. 7044)

_____ I am exempt under Sec.__________. Business and Professional Code for this reason _______________________________________________________________________________ _______________________________________________________________________________

WORKMENS 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 City of Alturas Building Dept., 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 in 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 is deemed revoked.

______________________________________________________________________________________

I certify that I have read this application and state that the above information is correct. I agree to comply to all City Ordinances and State Laws relating to building construction, and hereby authorize representatives of the City of Alturas to enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the City of Alturas against all liabilities, judgements, costs, and expenses which may in any way accrue against said City in consequence of the granting of this permit.

I hereby signify that I will comply with the restrictions above, as a condition of permit issuance.

X___________________________________________________Date_______

Signature of Applicant:_____ Owner_____ Contractor _____Agent

An OSHA permit is required for excavations over 5'0" deep and demolition or construction of structures over 3 stories in height.

*****************************************************************************************

Receipt #_______ Date_________ Amount: $________ APP #____________

Zone:__________ Flood:__________ Panel No.:__________Date_________

Setbacks: Front_________ Side_________ Rear_________ Other_______

Airport:_________________________ Parking_________________________

THIS PERMIT IS HEREBY ISSUED UNDER THE APPLICABLE

PROVISIONS OF THE CITY CODE AND/OR RESOLUTIONS TO

DO WORK INDICATED ABOVE FOR WHICH FEES HAVE BEEN PAID.

BUILDING OFFICIAL

By:___________________________________________Date_________

PERMIT EXPIRES: Date__________________________________

This permit is not valid unless signed and dated below by Building Dept. Representative certifying that

payment for permit has been received by City Treasurer.

____________________________________Date________________

Bldg. Dept. Representative

Fire Department and applicable sections of City of Alturas (Fire Safe Regulations)

__________________________________________________________

Plan act:

__________________________________________________________

CC&R's (other deed restrictions may apply)

_________________________________________________________

__________________________________________________________

Conditions:

__________________________________________________________

Approvals Required Prior to Building Permit Issuance:

_________________________________________________________

___________________________________ ___________________

Fire Department Date

___________________________________ ___________________

Public Works Director Date

___________________________________ ___________________

Planning & Zoning Director Date

PUBLIC WORKS Fee DEPT. USE Fee

_____Encroachment Permit _________ School Dept. ____________

_____Street Resection _________ Park Tax per Bdrm._________
Re:_________________________________________

_____Sidewalk_________________________________________

Re:____________________________________________________

_____ Curb & Gutter _________ Drainage Fees_______________

Re:______________ ___________A.C.______________________

_____ Water Connection _________ Planning Dept._____________

_____ Sewer Connection _________ Zoning Dept._______________

_____ Water Capital Imp. _________ Earthquake:_______________

_____ Sewer Capital Imp. ____________________________________

_____ Water Size 5/8 or 1"____________________________________

Other____________ ______________________________________

Comments:______________________________________________________

_______________________________________________________________