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
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