PMT15-00866 I
9
City of Menifee Permit No.: PMT15-00866
29714 HAUN RD.
MENIFEE, CA 92586 Type: Commercial Alteration
MENIFEE Date Issued: 04/07/2015
PERMIT
Site Address: 27168 NEWPORT RD, Suite#3, Parcel Number:
MENIFEE, CA 92584 Construction Cost: $0.00
Existing Use: Proposed Use: '.
Description of HOURLY INSPECTION FOR C OF 0"ALL KIDS DENTAL GROUP"
Work:
Owner Contractor
NEWPORT COMMONS LLC ,
27192 NEWPORT ROAD
SUITE 2
Applicant License Number:
MENIFEE, CA
Fee Description Qtv Amount I$1
8uil I ermltlssuarice,� �.e_ ..,._�' ,
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 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_Blog_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
❑ 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'//www.leoinfo.ca.aov/calaw.html.
permit is issued.My workers'compensation insurance carrier and policy number are:
Carrier roperty Owner or Authorized Agent Date
Expires Policy#
❑ By my Signature below, I certify to each of the fallowing: 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-
. ❑ 1 certify that in the performance of the work for which this permit is issued, I identi'ed property f�ection purposes.
shall not emolov 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 P erty 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, 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 zlCIO 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 ❑YES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION
Lender's Address FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
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 items) (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, O 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 Or
I HAVE READ THE HAZARDOUS MATERIAL
Section 7000)of Division 3 of the Business and Professions Code)or that he or O ES 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
E S ON 25505ERIAL 1';5533EPOR1, AND
25534 CONCERNING
El 1, 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 PRO R O 'fORiZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code; 11
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).
MAR/25/2015/WED 10: 18 AM City of Menifee PAX k 1-951-679-3843 P, 004
CERTIFICATEOF OCCUPANCY APPLICATION
�4menifee
DATE ��Z�//sue PERMIT NUMBER VKD5 'Uy X q
BUSINESS NAME dW � JS Ji�yrYt G�Layi TYPEOFBUSINESS o"_'
ADDRESS 2 2444 F�%g {�T�� o��L5T/ 3 101F
NAME OF BUSINESS OWNERS)
ADDRESS(IF DIFFERENT FROM ABOVE)
PHONE__ _[ >/ 7� `��IP_ EMAIL
OWNER OF BUILDING n/ a� l � ' v ` 6 Cy
ADDRESS /� n 4 11 *A
PHONE 1l ! '— ry EMAIL
DESCRIBE EXACT USE OF BUILDING: yl
City of Menifee
Building & Safety Dept.
PREVIOUS USE OF BUILDING/SUITE IJJ��� 8%�i �i
APPLE CANT ACKNOWLEDGEMENT
Applicant agree's that the Certificate of Occupancy shall be posted in a conspicuous location,awUl`q�rAta�lp�ct
to the City's issuance of the Certificate of Occupancy. C I V U
I, To, L/y 10�1 , hereby agree to comply with the above-described terms in this
Application for Certificate of occupancy.
7
DATE 1 L
ArPucaryr-
BUS LICENSE DATE ENGINEERING DATE
BUS LIC.NUMBER FIRE DATE
PLANNING DATE EMWD DATE
HEALTH DEPT DATE BUILDING DATE
REMARKS
City Of Menifee Building&Safety Deportment 29714 Houn Rd. Menifee, C4 92586 951-672-6777
www.cityofinenifee.us inspection Request Line
MAR/25/2015/WED 10. 19 AM City of Menifee FAX No. 1-951-679-3843 P. 005
i
DISCLOSURE •° CERTIFICATE OF OCCUPANCY
_��
iA zx e
,, Menifee
ADDRESS L r, G
BUSINESS NAME
INTENDED BUSINESS USE `G '
15 THIS NEW BUSINESS IN THE CITY OF MENIFEE? NO (CIRCLEONE)
ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? YES NO (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? / E9 NO (CIRCLE ONE)
SQUARE.FOOTAGE ✓ p Y 7 4r C /
NUMBER OF EMPLOYEES
NUMRERAND LOCATION OF RESTROOM FACILITIES 26a ?' / a,.A
LIST ANY TOXIC CHEMICALS, FLAMMABLE/CQMBUSTIBLE LIQUIDS OR GASES USED OR STORED WITH
MSDS SHEETS AND QUANTITIES OF EACH BELOW OR ON A SEPARATE ATTACHED SHEET(S);
i —
ARE YOU MAKING ANY IMPROVEMENT TO THE SUITE OR BUILDING OTHER THAN PAINTING,
PAPERING, FLOOR COVERING, MOVABLE CASES,SHELVING OR PARTITIONS NOT OV ''9" HIGH?
YES �'NO / (CIRCLE ONE)
• APPLICANTSHALL OBTAIN ALL REQUIRED CLEARANCES AND/OR APPROVALS FROM THE
APPROPRIATE WATER DISTRICT AND FIRE DEPARTMENT PRIOR TO ISSUANCE OF ANY
BUILDING PERMITS
SIGNATURE DATE
PRINTNAME cf
NAt�F'foWNER J CONTRACTOR / ARCHRECT / ENGINEER (CIRCLE ONE)
j FQR CITYSTAFF�/` PERMIT NUMRER LOUPANCYGRP TYPE QF CONST STAFF INITIALS
City of Menifee Building&.Sofety Department 29714 Haun Rd, Menifee, CA 92566 951-672-6777
www,dryofinenifee.us Inspection Request Line 951-245-6213