PMT15-00117 i
City of Menifee Permit No.: PMT15-00117
_ 29714 HAUN RD, Type: Commercial Alteration
';MCC�I.A. MENIFEE, CA 92586
MENIFEE Date Issued: 01/20/2015
PERMIT
Site Address: 26850 CHERRY HILLS BLVD, MENIFEE, Parcel Number: 337-310-016
CA 92586 Construction Cost: $0.00
Existing Use: Restaurant Proposed Use:
Description of HOURLY INSPECTION FOR CERTIFICATE OF OCCUPANCY FOR"MERNA'S CAFE&GRILL, INC"
Work:
Owner Contractor
STEVEN TAPLEY
26834 CHERRY HILLS BLVD
MENIFEE, CA 92586
Applicant License Number:
MERNA IBRAHIM
MERNA'S CAFE&GRILL INC
26850 CHERRY HILLS BLVD
MENIFEE, CA 92586
Fee Description Oyt Amount f$1
Inspections not specified 129 129.07
$156.07
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 building 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 License No. 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
❑ I am exempt from licensure under the Contractors'State License Law for the
❑ I 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
❑ 1 have and will maintain workers' compensation insurance, as required by Business and Professions Cade,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:htti3'llwww.leginfo.pa.ciov/calaw.html.
permit is issued.My workers'compensation insurance carrier and policy number are:
Carrier Property Owner or Authorized Agent Date
Expires Policy#
Name of Agent Phone# ❑ By my Signature below, I certify to each of the following: I am the property
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-
❑ I 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 I(Y1Q/m A� 1-).O'l S
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#
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, DYES 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 ❑NO 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 ❑NO DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
OWNER BUILDER DECLARATIONS GUIDE LINES
I hereby affirm under penalty of perjury that I am exempt from the Contractor's PRINT NAME:
License Law forlhe reason(s)indicated below by the checkmark(s)I have placed ❑YES 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 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, SECTION 25505 25533 AND 25534 CONCERNING
❑ I, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIAL REPOT 1YING.
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).
t 1 0 . .� I —r-s- 5, —• .c; .,. .
}{
DATE )Z I � lo PERMITNUMBER
BUSINESS NAME McR t-.�AS CKU UaIY-V Itvc TYPE OF BUSINESS e5�0.c yr
ADDRESS 907 0 (__Ve ffjj Vi\\5 op AaS&&
NAME OF BUSINESSOWNER(S) 1A2vna ( hVG )0--%
ADDRESS(IF DIFFERENT FROM ABOVE)
PHONE (OqfA� 9'\ A—S?V EMAIL ��I0.�l1Ml�POYtQ �Q�QcJ 1�o�n0.�l•Cd
OWNER OF BUILDING S V2'N� `Cw'.C'Df
ADDRESS�iQ`b�i� C�QVYH ylE \�s E lvd r P•o• ox 643 EMeY�c 2 f co
PHONE EMAIL
DESCRIBE EXACT USEBUILDING: 10t„o
PREVIOUS USE OF BUILDING/SUITE & Y — \)\Y`Q
APPLICANT ACKNOWLEDGEMENT
Applicant agrees that the Certificate of Occupancy shall be posted in a conspicuous location,and will operate subject
to the City's issuance of the Certificate of Occupancy.
I, kAU&an \�1C0.� d hereby agree to comply with the above-described terms in this
Application for Certificate of Occupancy.
f;
DATE 1 L
APPLICANT
o rr. ••s r
BUS LICENSE DATE ENGINEERING DATE
BUS LIC.NUMBER FIRE DATE
PLANNING DATE EMWD DATE
HEALTH DEPT DATE BUILDING DATE
REMARKS
City of Menifee Guildinn cC Snfety DepmYment 2971 r'Houn Rd. Menifee, CA 92586 951-672-6777 .
wlvw.cityofinenifee.us Inspection Request One
CERTIFICATE OF OCCUPANCY TENANT DISCLOSURE FORM
x's
{"Menifee
DATE I l PERMITNUMBECR N1 lt_rn 0011
ADDRESS � 50 q r\e� 1k J
BUSINESS NAME Mef ffL S
INTENDED BUSINESS USE
IS THIS ANEW BUSINESS IN THE CITY OF MENIFEE? Y S NO (CIRCLE ONE)
ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? YES (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRN KLERS? YES NO (CIRCLE ONE)
SQUAREFOOTAGE
NUMBER OF EMPLOYEES 6
NUMBER AND LOCATION OF RESTROOM FACILITIES
2-. �krk_ it kcy' ok x" a—
LIST ANY TOXIC CHEMICALS, FLAMMABLE/COMBUSTIBLE LIQUIDS OR GASES U D OR STORED WITH
MSDS SHEETS AND QUANTITIES OF EACH BELOW OR ON A SEPARATE ATTACHED SHEET(S):
• ARE YOU MAKING ANY IMPROVEMENT TO THE SUITE OR BUILDING OTHER THAN PAINTING,
PAPERING, FLOOR COVERING, MOVABLE CASES,SHELVING OR PARTITIONS NOT OVER 5' 9" HIGH?
YES NO (CIRCLE ONE)
• APPLICANT SHALL OBTAIN ALL REQUIRED CLEARANCES AND/OR APPROVALS FROM THE
APPROPRIATE WATER DISTRICT AND FIRE DEPARTMENT PRIOR TO ISSUANCE OF ANY
BUILDING PERMITS
SIGNATURE Imim.� DATE 1
PRINT NAME
ENAN / OWNER / CONTRACTOR / ARCHITECT / ENGINEER (CIRCLE ONE)
OCCUPANCY GRP TYPE OF CONST STAFF INITIALS
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92585 951-672-6777
www.cityofinenlfee.us Inspection Request Line 951-246-6213
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