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PMT14-03145 City of Menifee Permit No.: PMT14-03145 JX 29714 HAUN RD, I MENIFEE, CA 92586 Type: Residential Mechanical MENIFEE Date Issued: 1 210 212 01 4 PERMIT Site Address: 28392 CHAMPIONS DR, MENIFEE, CA Parcel Number: 340-110-036 92584 Construction Cost: $2,500.00 Existing Use: Proposed Use: Description of REPLACE GAS FURNACE ONLY Work: Owner Contractor DANIEL HIPPERT BEAR CREEK HEATING AND AIR CONDITIONING 28392 CHAMPIONS DR INC MENIFEE, CA 92584 24069 CHATENAY LANE Applicant Phone: 9516002882 BARRY DUNGAN License Number: 779461 BEAR CREEK HEATING AND AIR CONDITIONING INC 24069 CHATENAY LANE MURRIETA, CA 92562 Fee Description City Amount($) Building Permit Issuance 1 27.00 $177.00 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,orwhere the work commenced is suspended or abandoned for six months,shall expire,and fees paid shall be forfeited. AA Bldg_Permit Templaw.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 eff Code:The Contractor's License Law does not apply to an owner of a property License Class C2V Licensy�lo. Z� who builds or improves thereon, and who contracts for the projects with a Expires Signature �!) licensed contractor(s)pursuant to the Contractors State License Law). WORKERS'COMPENSATION DECLARATION ❑ lam exempt from licensure under the Contractors'Slate 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 ❑ 1 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,leainfo.ca.aovlcalaw.html. permit is issued.My workers'compensation insurance carrier and policy number are: Property Owner or Authorized Agent Date Carrier Expires 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- 0 1 certify that in the performance of the work for which this permit is issued,I id d property for the in 3s ion 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 property Owner or Aut oriz6 gent^ Date Code,1 shall forthwith comply With thosevisions. V ��_7 0 ` A City Business License# Date; IZ�2�, _\ Applicant; _ WARNING: FAILURE TO SECU E 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 OR A DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE MIXTURE CONTAINING A HAZARDOUS MATERIAL LABOR CODE, INTEREST,AND ATTORNEYS FEES DNO EQUAL TO OR GREATER THAN THE AMOUNTS CONSTRUCTION LENDING AGENCY SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? I hereby affirm that under the penalty of perjury there is a construction lending 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 ❑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 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, ❑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 I HAVE READ THE HAZARDOUS MATERIAL provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or DYES 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, SECTIOUS ON 25505RIALffE5533 GD 25534 CONCERNING HAZARPOkt ❑ 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 P PE TY OWNER AUTHORIZED A 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). F BU 1 APPLICATION Building & Safety Dep . DEC 0 2 2014 Menifee DATE Recehipid PERMIT/PLAN CHECK NUMBER �I��O TYPE: O COMMERCIAL &ESIDENTIAL 0 MULTI-FAMILY O MOBILE HOME 0 POOL/SPA 0 SIGN SUBTYPE: O ADDITION 0 ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL O NEW O PLUMBING 0 RE-ROOF-NUMBER OF SQUARES DESCRIPTION OF WORK ` Q 5 �yjY•y�( -Q• PROJECT ADDRESS 24 ,/�y,/ ASSESSOR'S PARCEL NUMBER _ � � ILO ' 0, W LOT 3kpTRACT OWNER NAME , mv ADDRESS SC� C,,� 0- PHONE '1 60—qOl —�Z`� EMAIL APPLICANT NAME �Y�, y, ✓� r� w C )` ADDRESS Cy�(�,, PHONE y� EMAIL CONTRACTOR'S NAME '(` 1� �(`�(` OWNER BUILDER? OYES ONO BUSINESS NAME • '��.7—o'r ADDRESS 'XNvvw p,� Q PHONE q,S I'C�O(`�-'ZSS EMAIL L'tcQ� 1,�RTC@ a t IA CONTRACTOR'S LICENSE CLASSIFICATION ^STTATE LIC NUMBER C26 VALUATION $ L W, SQ FT �[j� L SQ FT 2,2- 1 tl APPLICANT'S SIGNATURE DATE CITY STAFF USE ONLY DEPARTMENT DISTRIBUTION CITY OF MEN 7USINESS LICENSE NUMBER BUILDING PLANNING ENGINEERING FIRE GREEN ( SVIP INVOICE AMOUNT I ^� ^ PAID AMOUNT � I <3 CASH Ci CHECKq OCREDITCARD VISA/MC PLAN CHECK FEES PAID AMOUNT 0CASH C%CHECKq OCREDITCARD VISA/MC OWNER BUILDER VERIFIED OYES 0 NO DL NUMBER NOTARIZED LETTER ii YES O NO City of Menifee Building& Safety Department 29714 Haun Rd. Menifee, CA 92586 951-672-6777 www.cityofinenifee.us Inspection Request Line 951-245-6213 M. 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