PMT14-03122 i
i
City of Menifee Permit No.: PMT14-03122
29714 HAUN RD. Type: Residential Plumbing
MENIFEE, CA 92586
MENIFEE Date Issued: 1 112 5/2 01 4
iIt
V
PERMIT
Site Address: 28723 BROADSTONE WAY, MENIFEE, Parcel Number: 340-122-023 .
CA 92584 Construction Cost: $700.00
Existing Use: Proposed Use:
Description of REPLACE 40 GALLON WATER HEATER LOCATED IN GARAGE
Work:
Owner Contractor
ANDREW ROMERO INTER-CITY ENERGY SYSTEMS INC
28723 BROADSTONE WAY 12252 MC CANN DRIVE
MENIFEE, CA 92584 SANTA FE SPRINGS, CA 90670
Applicant Phone: 5627771142
TERESA DINTERMAN License Number: 587709
INTER-CITY ENERGY SYSTEMS INC
12252 MC CANN DRIVE
SANTA FE SPRINGS, CA 90670
Fee Description QQrt Amount l$)
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_Bldg_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 license is in full for a effft. Code:The Contractor's License Law does not apply to an owner of a property
License Class License No. y(�� who builds or improves thereon, and who contracts for the projects with a
Expires&f. , Signatures _ licensed contractor(s)pursuant to the Contractors State License Law).
WORKERS'COMPENSATION DECLARATION
❑ I am exempt from licensors 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.
Policy# built as an owner-building if it has not been constructed in its entirety by licensed
contractors. I understand that a copy of the applicable law, Section 7044 of the
❑ 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:hftp-/Iwww.iQainfo.ca,cigv/calaw.html.
permit is issued.
/My workkerss'''compensation�ins�uranc�e carrier and policy number are:
/��/�/1-01 (�i),r'IL— 'f'7dz'�-S' z Property Owner or Authorize gent Date
Carrier
Expires l Policy# (�- ��� )���
❑ 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-
El I certify that in the performance of the work for which this permit is issued,I identified property for the inspection purpose
shall not a any persons in any manner dogs to become subject to the
workers'compensation
ensation laws of California, and agree that if I should become
subject to the workers'compensation provisions of Section 3700 of the Labor Property Owner or Authorized Agent Date
Code,I shall forthwith comply with those provisions
+% City Business License# � -3
Date; 1/ / 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, OYES OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE MIXTURE CONTAINING A HAZARDOUS MATERIAL
LABOR CODE, INTEREST,AND ATTORNEYS FEES ONO 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 OYES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION
FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
Lender's Address ❑NO DISTRICT(SCAQMD) SEE PERMITTING CHECKLIST FOR
GUIDE LINES
OWNER BUILDER DECLARATIONS
I hereby affirm under penalty of perjury that I am exempt from the Contractor's PRINT NAME:
License Law for the reason(s)indicated below by the checkmark(s)I have placed OYES 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, ❑NO 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
provisions of the Contractor's State License Law(Chapter 9 (commencing with I HAVE READ THE HAZARDOUS MATERIAL
Section 7000)of Division 3 of the Business and Professions Code)or that he or OYES INFORMATION GUIDE AND THE SCAQMD PERMITTING
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($500).) CODE, SECTION 25505 25533 AND 25534 CONCERNING
❑ 1, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIAL I';EPORNG.
compensation, will do( )all of or( ) porting of the work, and the structure is PROPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property X
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale. If,however,
the building or improvement is sold within one year of completion, the Owner-
Builder will have the burden of proving that it was not built or improved for the
purpose of sale).
CITY OF la/IlENI F1EE
PLCK No: P it I
29714 Haun Road �a-
Date: Date:
Menifee, CA 92586 l+
Phone: (951)672-6777 Amount: Amount:
Fax:(951)679-3843
Ck#: Ck#:
Building Combination Permit G
To Be Completed By Applicant
Legal Description: y Planning Case: F: L: Rt: R;
Probe Address: �J Assessor's Pacel Number.
�2 �YDG r ,� '-�— 1 --t9-3
Projectlienant ame;
v Unit#: Floor#.,
Name: ,^ _ _L f v Phone No. Fax No.
Property A r '1
Owner �. Unit Number Zip Code
Email Address: S`-
Name: 7
. ?� Phone No,T Fax No_
Applicant Address: .
7 r /l, , Unit Number Co Zi de�
Email Address: xJ- � �tcC � �L/V-1 �,Gt' pc-
Name:
LL—
P�S�No. Fax No.
Contractor Address �J �.l - f Cih, ) St [e Zip C e✓ �, c„ CLeu lUc�. C .b1.rS rC: �' gs1
Contractors Business License No_ :f'
Contractor's City Slate of Calm�a License No
,.� Classiricat'On C,
Number of Squares:
Square Footage
Des ription of Work: AaC / �rQ Cost of Work:$ OO of Applicant's Signs e -
�' ' Date:
To Be ompleted By City Staff Only _
Indicate As R-Received or NIA-Not Applicable
5 Completes sets of fully dimensioned,drawn to sale plans which include: 1 set of documents which include
❑ Tille Sheet ❑ Elevations ❑ Electrical Plan ❑ Gen Tech/Soils Report(on cd only)
Mechanical Plan Title 24 Energy r z
❑ Plot/Site Plan ❑ Roof Plan ❑
❑ gy(on 8 x 77)
❑ Foundation Plan ❑ Cross Section ❑ Plumbing Plan ❑ Structural Calculations
❑ Floor Plan ❑ Single Line dlagram for elec.services over 400 AMP
❑ Structural Framing Plan&Details ❑ Shoring Plan ❑ Sound Report-Residential
Class Code: Indicate New Construction Alteration' Addition" Means/Methods
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 it Indicate all Geo-tech.Haz.Zone
At Project Sprinklered YES or NO
Completion: Construction that apply: Coastal Zone
Type(s): C Of O YES or NO Noise Zone
Required? Listed on Historic Resources Inventory
CITY PLANNING STAFF ONLY
APPROVALS: Costal Commiss Arch.Review Board Landmark Comm. Planning Comm.Zoning Administrator
Fee Exempt: City Project Elec.Vehicle Charger Landmark Seismic Retrofit special case:Bldg.
OffdalA must
Expedite Project(s): Child Care City Project Green Building Landmark Affordable Housing
For Staff Use Only
Building/Safely Permit Specialist I City Planning Civd Engineenng EPWM-Atlmin Transportation MgmL Renl Control
THANK YOU FOR HELPING US CREATE A BETTER COMMUNITY
CITY OF MENIFEE
ENIF Department of Building and Safety
Contractor Declaration
LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under the provisions of Chapter 9
(connecting with Section 7000)of Division 3 of the Business and Professions code and my license is in full force and effect.
License Class: C � Sd '770 9
CJ License No: ""
Exp.Date 07 / Contractor: yC_��L, �
❑ OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors 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 to its issuance,also requires the applicant for such permit to file a signed statement that he or she
is licensed pursuant to the provisions of the Contractors License Law(chapter 9[commencing with Section 7000]of Division 3 of the
Business and Professions Code)or that he or she is exempt there from and the basis for the alleged exemption. Any 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 [$500.00]:
n I,as the owner of the property,or my employees with wages as their sole compensation,will be the work,and the structure is not intended
or offered for sale(Sec.7044, Business and Professions code: The Contractor License Law does not apply to the 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 sale. If,however,the building or improvement is sold within one year of completion,the
owner-builder will have the burden of proving that he/she did not build or improve for the purpose of sale).
❑I,as owner of the property,am exclusively contracting with license contractors to construct the project(Sec.7044 Business and
Professions Code: The Contractor License Law does not apply to an owner of property who builds or improves thereon,and who
contracts for such projects with a contractor(s)license pursuant to the Contractors License Law).
❑ I am exempt under Sec. B&P.C.for the reason
Date: Owner:
WORKERS COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a certificate of consent to self-insure for worker compensation,as provided for by Section 370 of the Labor Code,
for the performance of the work for which this permit is issued
011"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. M/y�Workers Compensation Insurance carrier and policy Number are:
Carriei .K4 l&✓( L,6{� L, -- f/Y-e � co policy Number. ya 6333d2S--
(This section need not be completed if the permit is for one hundred dollars($100.00)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 the workers compensation laws of California,and agree that if I should become subject to the workers compensation provisions of
Sec.3700 of the Labor Code,II shall forthwith comply with those provision
Date: /(f�J 6111 1- Applicant:
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 SEC.3706 FOR THE LABOR CODE,INTERST,AND ATTORNEY FEES.
CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction-lending agency for the performance
of the work for which this permit is issued(Sec.3097,Civic C.).
Lender's Name:
Lender's Address:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify that I have read this application and state that the above
information is correct. I agree to comply with all City ordinances and state laws relating to building construction,and hereby authorize
representathr _ of the City to enter upon the above mentioned property for inspection purposes.
X --Z /e t9 'rJ-Ptr✓Ytr .�
Signature of plican Agent Print ApplicanVAgent Name Date
INSPECTION INFORMATION:Work may proceed only at the direction of the field inspector. To request an inspection Of Work Completed,Call
the number(951)672.4777. Inspection request must be called in the day before to assure next day inspections.
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