PMT15-01041 i
City of Menifee Permit No.: PMT16-01041
_ 29714 HAUN RD.
';f%�GC�1.1..% MENIFEE, CA 92586 Type: Residential Re-Roof +:
MENIFEE Date Issued: 0412 2/2 01 6
PERMIT
Site Address: 26252 BALDY PEAK DR, MENIFEE, CA Parcel Number: 338-211-002
92586 Construction Cost: $10,000.00
Existing Use: Proposed Use:
Description of REROOF OVER 1 LAYER WITH OWENS CORNING COOL ROOF SHINGLES
Work:
Owner Contractor Ili
WALTER MURPHY ROGER HUMPHRIES ROOFING
26252 BALDY PEAK DR P 0 BOX 1094
MENIFEE, CA 92586 MURRIETA, CA 92362
Applicant Phone: 9516776953
ROGER HUMPHRIES License Number: 378768
ROGER HUMPHRIES ROOFING
P 0 BOX 1094
MURRIETA, CA 92362
Fee Description ON Amount )
Building Pemilssuar cep 27'00;
Inspections not specified 98 �. 98.00
$126.00
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 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_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 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 V full force and effect. Code:The Contractor's License Law does not apply to an owner of a property
License Class C`_-59 who builds or improves thereon, and who contracts for the projects with a
Expires 77/, lfa Signatu licensed contractor(s)pursuant to the Contractors State License Law).
WORKERS'COMPENSATION DECLA TION
❑ lam exempt from licensure under the Contractors'Slate License Law for the
)11 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 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:http'llww_N.IeqInfo.ca.gov/caIaw.htmI.
permit is issued.My workers'compensation insurance carrier and policy number are:
Carrier_-V--- )w __ roperty caner or Authorized Agent Date
Expires l2 11 =5 Policy#290-0�12-77(R
❑ 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 stale laws relating to building
constructi .I au ize rep sentatives of this city or county to enter the above-
. ❑ 1 certify that in the performance of the work for which this permit is issued, erty or t pecl'on 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 provisi ns of Section 3700 of the Labor
Code,I shall forthwith comply with t se prov9i ion . Prope Owns or Autho zed Agent Date
City Business License#
1 03� gag
Date; �-•ZZ• Ici 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, DYES 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 -kNO
EQUAL TO OR GREATER THAN THE AMOUNTS
CONSTRUCTION LENDING AGENCY 1 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
�1 FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
W"
Lender's Address O 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, 99140 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($500).) CODE, SECTION 25505 25533 AND 25534 CONCERNING
❑ I, as owner of the HAZARD US MATERIAL I}EPORtING.
property, or my employees with wages as their sole
compensation,will do( )all of or( )porting of the work,.and the structure is OW A HOFAZEDAGENT
not intended or offered for sale.(Section 7044,Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale.If,however,
the building or improvement is sold within one year of completion,the Owner-
Builder will have the burden of proving that it was not built or improved for the
purpose of sale).
APPLICATIONBUILDING & SAFETY PERMIT/PLAN CHECK
4Menifee
DATE 42 y . 15 PERMIT/PLAN CHECK NUMBER M 1T�'1' Olo I
TYPE: COMMERCIAL O RESIDENTIAL " MULTI-FAMILY O MOBILE HOME " POOL/SPA Q SIGN
SUBTYPE: O ADDITION C,ALTERATION CO DEMOLITION 0 ELECTRICAL O MECHANICAL
ONEW " PLUMBING °LRE-ROOF-NUMBER OF SQUARES 17
DESCRIPTION OF WORK 'w L
PROJECTADDRESS 2 2- eALtq
K/ • Z-
ASSESSOR'S PARCEL NUMBER OV a LOT TRACT ac
OWNER NAME m . f,. musxov
S�
ADDRESS L-025 Z PAIug 'Pr-A- • S vw C � Z
PHONE (pig • !122 • 2,9(0 EMAIL
APPLICANT NAME V S
ADDRESS
PHONE EMAIL
CONTRACTOR'S NAME OWNER BUILDER? 0 YESX NO
BUSINESS NAME
ADDRESS (p L,
PHONE 'j;3t .(o-6��BIB EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION C'
1
VALUATION$ S L SO FT
APPLICANT'S SIGNATURE DATE
CITY STAFF USE ONLY
DEPARTMENT DISTRIBUTION CITY OF ME EE UpSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN 1� SMIP 00.�-O
INVOICE I PAID AMOUNT
AMOUNT I C%CASH C%CHECK# '..'CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT JCASH ':r CHECK# :CREDIT CARD vlsA/Mc
OWNER BUILDER VERIFIED :)YES NO DL NUMBER NOTARIZED LETTER £i YES Ci NO
City of Menifee Building& Safety Department 29714 Houn Rd. Menifee, CA 92585 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-245-6213
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