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PMT15-01347 W City of Menifee Permit No.: PMT15-01347 29714 HAUN RD.'9CCCEL MENIFEE, CA92586 Type: Residential Electrical 6""' As°k." MENIFEE Date Issued: 05/19/2016 PERMIT Site Address: 28409 KING APACHE CIR, MENIFEE, CA Parcel Number: 388-021-005 92584 Construction Cost: $9,000.00 Existing Use: Proposed Use: i Description of REMOVE EXISTING TUB, INSTALL WALK-IN TUB, 2 OUTLETS, 1 GFI, 1 20AMP BREAKER, MINOR Work: DRYWALL REPAIR Owner Contractor JOSEPH RUSSO SAFE STEP WALK-IN TUB COMPANY INC 28409 KING APACHE CIRCLE 15262 PIPELINE LANE MENIFEE, CA 92584 HUNTINGTON BEACH, CA 92649 Applicant Phone: 7143738545 DAVID BOYANER License Number: 983603 SAFE STEP WALK-IN TUB COMPANY INC 15262 PIPELINE LANE HUNTINGTON BEACH, CA 92649 Fee Description Qtv Amount Building Permit Issuance 1 27.00 $149.00 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 Cod d 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 IN q9-S& 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 ❑ 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.leginfo.ca.gov/calaw.htm]. permit is issued.My wo kers'compensation insurance carrier and policy number are: Carrier Ili Property Owner or Authorized Agent Date Expires ❑ 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- ❑ I certify that in the performance of the work for which this permit is issued, I identified erty 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 a re that if 1 should become subject to the workers'compensation provisions of Se tion`3 of the Labor property wrier or Authorized Agent Date Code, I shall forthwith comply with ovisions. ,!— > City Business License# Dat, ) � S 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, ❑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 ❑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 OYES 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 for the reasons)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, ❑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 ❑YES 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($500).) CODE, SECTION 25505, 25533 AND 25534 CONCERNING ❑ 1, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIAL REPORtING. compensation,will do( ) all of or( ) porting of the work, and the structure is PROPERTY OWNER OR AUTHORIZED AGENT not intended or offered for sale.(Section 7044,Business and Professions Code; The Contractor's State License Law does not apply to an owner of a property X who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale.If,however, the building or improvement is sold within one year of completion,the Owner- Builder will have the burden of proving that it was not built or improved for the purpose of sale). & SAFETY PERMIT/PLAN CHECK APPLICATION I Menifee DATE �- /�/' PERMIT/PLAN CHECK NUMBER TYPE: O COMMERCIAL RESIDENTIAL 0 MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN SUBTYPE: ::) ADDITION <)ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL O NEW O PLUMBING ORE-ROOF-NUMBER OF SQUARES DESCRIPTION OF WORK �CQIMpV2, I Le,Y�cl�.e. PROJECT ADDRESS Kiytz,, I C L I_ ('I C ASSESSOR'S PARCEL NUMBER ��'4Z_ LOT TRACT OWNER NAME fe ttis Q City Of Menlfee nont ADDRESS �gL,(v0I 'L +�, C �df PHONE EMAIL APPLICANT NAME � Received ADDRESS j �� , Ca . 4f PHONE EMAIL CONTRACTOR'S NAME r f OWNER BUILDER? 0 YES BUSINESSNAME ( '�'... P W ( b ADDRESS � PHONE -1�i- 323 tI EMAIL c CONTRACTOR'S STATE LIC NUMBER d(W 6�3 LICENSE CLASSIFICATION VALUATION$ SO.FT L SO FT APPLICANT'SSIGNATURE D E S�(�" OTYSTAFFUSEONLY DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER BUILDING PLANNING ENGINEERING FIRE GREEN SMIP INVOICE PAID AMOUNT A AMOUNT , � 1 OCASH OCHECK# OCREDIT CARD VISA/MC PLAN CHECK FEES PAID AMOUNT O CASH O CHECK# O CREDIT CARD VISA/MC OWNER BUILDER VERIFIED OYES :) NO DL NUMBER NOTARIZED LETTER O YES ' NO City of Menifee Building & Safety Department 29714 Houn Rd. Menifee, CA 92586951-672-6777 www,cityofinenifee.us Inspection Request Line 951-246-6213