PMT14-01017 City of Menifee Permit No.: PMT14-01017
29714 HAUN RD. Type: Residential Plumbing
MENIFEE, CA 92586
6axima ksMnwo MENIFEE Date Issued: 05/07/2014
PERMIT
Site Address: 30681 PIER POINTE CIR, MENIFEE, CA Parcel Number: 364-172-011
92584 Construction Cost: $1,760.00
Existing Use: Proposed Use:
Description of WATER HEATER REPLACEMENT, SAME LOCATION
Work:
Owner Contractor
GINA KEITER A R S AMERICAN RESIDENTIAL SERVICES OF
30681 PIER POINTE CIRCEL CALIFORNIA INC
MENIFEE, CA 92584 965 RIDGE LAKE BLVD STE 201
Applicant Phone: 5107296044
A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIj License Number: 765155
1520 W LINDEN STREET
RIVERSIDE, CA 92507
Fee Description Ott! Amount
Building Permit Issuance 1 27.00
$111.00
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errors in the plans and
specifications or from preventing builiding operations being carried on thereunder when in violation of the Building Code or of any other
ordinance of City of Menifee. Except as otherwise stated,a permit for construction under which no work is commenced within six
months after issuance, or where the work commenced is suspended or abandoned for six months,shall expire,and fees paid shall be
forfeited.
AA_Bidg_Permit Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION
I hereby affirm under penalty or perjury that I am licensed under provisions of ❑ I, as owner of the property an exclusively contracting with licensed
Chapter 9(commencing with section 7000)of Division 3 of the Business and contractors to construct the project(Section 7044, Business and Professions
Professions Code and my license is in full force and effect. Code:The Contractor's License Law does not apply to an owner of a property
License Class v c�/L Licensee No.
�mj/5'/�i S� who builds or improves thereon, and who contracts for the projects with a.
Expires- / /L( Signature_`I licensed contractor(s)pursuant to the Contractors State License Law).
WORKERS'COMPENSATION DECLARATION
❑ I am exempt from licensure under the Contractors'State License Law for the
❑ 1 hereby affirm under penalty of perjury one of the following declarations: following reason:
I have and will maintain a certificate of consent of self-insure for workers' By my signature below I acknowledge that, except for my personal residence in
compensation,issued by the Director of Industrial Relations as provided for by which I must have resided for at least one year prior to completion of
Section 3700 of the Labor Code, for the performance of work for which this improvements covered by this permit, I cannot legally sell a structure that I have
permit is issued. built as an owner-building if it has not been constructed in its entirety by licensed
Policy# contractors. I understand that a copy of the applicable law, Section 7044 of the
IY I have and will maintain workers' compensation insurance, as required by Business and Professions Code,is available upon request when this application is
section 3700 of the Labor Code, for the performance of the work for which this submitted or at the following Web site:http'//www leginfo ca oov/calaw html.
permit is issued.My workers'compensation insurance carrier and policy number are:
Properly Owner or Authorized Agent Date
Carrier L I?Z'!4 '� 'rfl5�. tlirt� L
Expires 10h /14 Policy# � 7-L 31-5°$C3f-Ul"0
❑ By my Signature below, I certify to each of the following: I am the property
Name of Agent Phone# owner or authorized to act on the property owner's behalf. I have read this
(This section need not be completed if the permit is for application and the information I have provided is correct. I agree to comply
one-hundred dollars($100)or less) 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-
0 1 certify that in the performance of the work for which this permit is issued,I identified property for the inspection purposes.
shall not employ any persons 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,Ishall forthwith comply with those provisions. Property Owner or Authorized Agent Date
City Business License# O �5 7 22
Date; Applicant;
WARNING: FAILURE TO SECURE WORKERS' HAZARDOUS MATERIAL DECLARATION
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS WILL THE APPLICANT OR FUTURE BUILDING
($100,000), IN ADDITION TO THE COST OF COMPENSATION, ❑YES OCCUPANT HANDLE A HAZARDOUS MATERIAL ORA
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE MIXTURE CONTAINING A HAZARDOUS MATERIAL
LABOR CODE, INTEREST,AND ATTORNEYS FEES 2M EQUAL TO OR GREATER THAN THE AMOUNTS
CONSTRUCTION LENDING AGENCY SPECIFIED ON THE HAZARDOUS MATERIALS
I hereby affirm that under the penalty of perjury there is a construction lending
INFORMATION GUIDE?
agency for the performance of the work which this permit is issued (Section WILL THE INTENDED USE OF THE BUILDING BY THE
3097 Civil Code) APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE
- Lender's Name DYES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION
FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
�
Lender's Address 0 DISTRICT(SCAQMD) SEE PERMITTING CHECKLIST FOR
GUIDE LINES
OWNER BUILDER DECLARATIONS PRINT NAME:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the reason(s)indicated below by the checkmark(s)I have placed DYES WILL THE PROPOSED BUILDING OR MODIFIED FACILITY
next to the applicable item(s)(Section 7031.5. Business and Professions Code: /- BE WITHIN 1000 FEET OF THE OUTER BOUNDARY OF A
Any city or county that requires a permit to construct, alter, improve, demolish, �U SCHOOL?
or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the I HAVE READ THE HAZARDOUS MATERIAL
provisions of the Contractor's State License Law (Chapter 9 (commencing with INFORMATION GUIDE AND THE SCAQMD PERMITTING
Section 7000)of Division 3 of the Business and Professions Code)or that he or ES
she is exempt from licensure and the basis for the alleged exemption. Any CHECKLIST. I UNDERSTAND MY REQUIREMENTS
violation of Section 7031.5 by any Applicant for a permit subjects the applicant to ❑NO UNDER THE STATE OF CALIFORNIA HEALTH AND SAFETY
a civil penalty of not more than($500).) CODE,
SECTOUS IOAN 25505AL kE5533�MN D 25534 CONCERNING
❑ I, as owner of the property, or my employees with wages as their sole
compensation, will do( )all of or( )porting of the work, and the structure is PROPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale.If,however,
the building or improvement is sold within one year of completion,the Owner-
Builder will have the burden of proving that it was not built or improved for the
purpose of sale).
CIT Y OF MENIFE�ty of Menifee PLCK No: Permit No:
29714 Haun Road Building & Safety Dept. '-O e)
Date: Date:
Menifee, CA 92586 MAY 01 2014 5 -1 1
Phone: (951)672-6777 Amount: Amount
ov
Fax:(951)679-3843 received Ck#: Ck#:
Building Combination Permit
To Be Completed By Applicant
Legal Description: A. l le e 1 r / Planning Case: F:
Property Address: 'Y Assessor's Parcel Number.
ProjecItTenant Name: Unit#: Floor#:
Name: Phone No. Fax No.
C ; e'} COI 97 -C (�
Owner Property Address: 2 O G l -N�-e c (2 Unit Number Zip Code
J �t� {�Ol azs
Email Address:
Name: Phone No.
Fax No.
Applicant Add�p Unit Number Zip Code
I5; r Tr// `'v (j1'C e- Sl -T,755e—(
Email Address: Ed
Name: 5 OL)-k-;--e— Phone No. Fax No.
Contractor Address: City Stale Zip Code
Contra cto�s rty2 ess License o. Contractor's Cily Slate of California License No. Classification:
7�5I C G C Z
Number of Squares:
Square Footage
Description of Work: '�nn Cost of Work:$
Applicant's Signature r Date:
5- 7 / 1-(
I be completed BY.City Staff Only
Indicate As R-Received or NIA-Not Applicable
5 Completes Sets of fully dimansuned,drawn to sale plans which include: 1 set of documents which include
❑ Title Sheet ❑ Elevations ❑ Electrical Plan ❑ Gen Tech/Soils Report(on cd only)
❑ Plot I Site Plan ❑ Roof Plan ❑ Mechanical Plan ❑ Title 24 Energy(on 8 Y:x 11)
❑ Foundation Plan ❑ Plumbing Plan El Structural Calculations
❑ Crass Section ❑ Single Line diagram for elec.services over 400 AMP
❑ Floor Plan ❑ Structural Framing Plan 8 Details ❑ Shoring Plan ❑ Sound Report-Residential
Class Code: Indicate New Construction Alteration' Addition• Means/hlathods
Work Type: Repair' Retrofit' Revision to Existing Permit' Required? YES NO
Proposed Building Use(s): Existing Building Use(s):
#Buildings: #Units: #Stories: Will the Building Have a Basement?
Y of N
Bldg, Code Occupancy Group Indicate Indicate if YES or NO Indicate all Geo-tech.Haz.Zone
Al Project Construction Sprinklered that a I Coastal Zone
Completion: pp y'
Type(s): C Of O YES or NO Noise Zone
Require I? Listed on Historic Resources Inventory
CITY PLANNING STAFF ONLY
APPROVALS: Costal Commiss Arch.Review Board Landmark Comm. Planning Comm.Zoning Administralor
Fee Exempt: City Project Elec.Vehicle Charger Landmark I Seismic Retrofit speclal case:e,og.
Olficial AccrJ43I
Expedite Project(s): Child Care City Project Green Building Landmark Affordable Hosing
For Staff Use Only
euildinglsalely Permit Specialist City Planning unit Engineering I EPWpA-Admin fransporlalion Mgml. Rer,l Control
THANK YOU FOR HELPING US CREATE A BETTER COMMUNITY