PMT15-00815 1
City of Menifee Permit No.: PMT15-00816
29714 HAUN RD, Type: Commercial Electrical
'cACCEEI.A— MENIFEE, CA92586
MENIFEE Date Issued: 04/16/2015
III
PERMIT
Site Address: 26660 ENCANTO DR, MENIFEE, CA Parcel Number: 331-120-065
92585 Construction Cost: $1,500.00
Existing Use: Proposed Use:
Description of REPLACE 6 EXISTING OUTLETS INSIDE STORE
Work:
Owner Contractor
DONALD SHELDRAKE-POLLY INC. SUPERIOR ELECTRICAL MECHANICAL&
2660 N MAIN ST PLUMBING INC
SANTA ANA, CA 92705 8613 HELMS AVE
Applicant Phone: 9093579400
DANIEL CANTERO License Number: 911185
SUPERIOR ELECTRICAL MECHANICAL&PLUMBING INC
8613 HELMS AVE
RANCHO CUCAMONGA, CA 91730
Fee Description 0yt Amount
XReceptacle Swdch Outlet&Fudue Bui Siv y �4100y
lding Permit Issuance 1 27.00
$169.00
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 sI
of Divisio6Vf�k usiness nd contractors to construct the project(Section 7044, Business and Professions
Professio e ryy��cenprd Code:The Contractor's License Law does not apply to an owner of a property
License las (( �,,�J Lic who builds or improves thereon, and who contracts for the projects with a
Expire Z �pignatur licensed contractor(s)pursuant to the Contractors State License Law).
WORKE S'CO PENSATI
❑ 1 am 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 of legally sell a structure that I have
permit is issued. built as an owner-buildin it has not been c structed in its entirety by licensed
Policy# co ctors. I understa th t a copy of the ap Iicable law, Section 7044 of the
l%- I have and will maintain workers' compensation insurance, as required by B in e s and ssic s ,is available up n request when this application is
section 3700 of the Labor Code, for the performance of the work for which this s mitt r the ing W si :/ .le info.ca. ov/ Iaw.html.
permit is issued.My workers'com ensation insurance carrier and policy number are: cs, (�
� �S 1\ c Pro art o uthori dDate
Carrier K— �` CJN`
Expires (�L )�-� Policy# //���
Phone 0- ES By my Signature below, I certify to each of the following: I am the property
Name of Agen � � 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 pr ided is correct. I agree to comply
one-hundred dollars($100)or less) with all applicable city a unty ordinance and state laws relating to building
c n uction.I thoriz r p entatives of thi 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 nti d prop rty t e i ction purposes.
shall not emolov any persons in any manner so as to become subject to the
workers'compensation laws of California, and agree t I shoul e ;
subject to the workers'compensatifn ' 'ons a lion 00 the Lab r property wne or Authorized Agen to
Code, shall forthwith comply with tov io s. � 5City Business Li ense#Date; ( Applic
WARN NG: FAILURE TO ECURE WORKERS' HAZARDOUS MATERIAL DECLARATION
COMPENSATION COVERAGE IS UN WFUL, 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 RK0_ 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
"V 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, 2'46 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 O U ER THE STATE OF CALIFORNIA HE AND SAFETY
a civil penalty of not more than($500).) tPE
, SECTION 2550 3 A 5534 C CERNING
❑ I, as owner of the property, or my employees with wages as their sole OUS M IA EP. �I
compensation,will do( )all of or( )porting of the work, and the structure is W ER O AUTH IZED 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).