PMT15-01564 City of Menifee Permit No.: PMT15-01564
29714 HAUN RD. Type: Residential Re-Roof
CA— MENIFEE, CA 92586
Gam. AsWk�a MENIFEE Date Issued: 06/0912015
i
PERMIT
Site Address: 27204 HOWARD ST, MENIFEE, CA 92586 Parcel Number: 335-312-010
Construction Cost: $6,500.00
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING SHINGLES, INSTALL R-38 INSULATION IN THE ATTIC, INSTALL NEW
Work: ASPHALT SHINGLES
Owner Contractor
JERRY BURGESS BAKER ROOFING CORPORATION
27204 HOWARD STREET 29515 DUNKIRK STREET
MENIFEE, CA 92586 MENIFEE, CA 92586
Applicant Phone: 9512557237
LARRY BAKER License Number: 884731
BAKER ROOFING CORPORATION
29515 DUNKIRK STREET
MENIFEE, CA 92586
Fee Descrriipptiiroyfn, Qtv Amount($1
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 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 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
LicenseClass to License N f
who builds or improves thereon, and who contracts for the projects with a i Expires Tres ( Signature d JJ licensed contractor(s)pursuant to the Contractors State License Law),
WORKERS'COMPENSATION DECLARATION
❑ 1 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'
compensation,issued by the Director of Industrial Relations as provided for by By my signature below I acknowledge that, except for my personal residence in
Section 3700 of the Labor Code, for the performance of work for which this which I must have resided for at least one year prior to completion of
permit is issued. improvements covered by this permit, I cannot legally sell a structure that I have
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 action 3700 of the Labor Code, for the performance of the work for which this submitted or at the following Web site:htti)://www.lealof ca gov/calaw html.
permit is issued,My workers'compensation insurance carrier and policy number are:
Carrier —iI v_Vy _J roperty Owner or uthonzed Agent Date
Expires_1� .<<�� - (' 5— 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 any persons in any manner so as to become subject to the
compensation
.//
workers'compensation laws of California, and agree that if I should become / �1
subject to the workers'compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. Property Owner or Authorized A ent Date
Date; a Applicant; 7 >f� City Business License# �a(� �i d
WARNING, FAILURE TO SECURE WORKERS'
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL HAZARDOUS MATERIAL DECLARATION
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, AYES OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND ATTORNEYS FEES MIXTURE CONTAINING A HAZARDOUS MATERIALEQUAL 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
3097 Civil Code) WILL THE INTENDED USE OF THE BUILDING BY THE
Lender's Name APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE
OYES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION
Lender's Address _ FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
O 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 reason(s)indicated below by the checkmark(s)I have placed
next to the applicable item(s)(Section 7031.5. Business and Professions Code: []YES WILL THE PROPOSED BUILDING OR MODIFIED FACILITY
Any city or county that requires a permit to construct, alter, improve, demolish, 0 BE WITHIN 1000 FEET OF THE OUTER BOUNDARY OF A
or repair any structure, prior to its Issuance, also requires the applicant for the �` SCHOOL?
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 AYES 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 y@'NO UNDER THE STATE OF CALIFORNIA HEALTH AND SAFETY
a civil penalty of not more than($500).) I- CODE, SECTION 25505 25533 AND 25534 CONCERNING
❑ 1, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIAL 4tEPORTING.
compensation,will do ( ) all of or( ) porting of the work, and the structure is PROPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property X
IS
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale,If,however,
the building or Improvement Is sold within one year of completion, the Owner-
Builder will have the burden of proving that it was not built or improved for the
purpose of sale).
BUILDING ♦ SAFETY PERMIT/PLAN APPLICATION
AMenifee
DATE L9 1q Is PERMIT/PLAN CHECK NUMBER
TYPE: []COMMERCIAL ZRIESIDENTIAL MULTI-FAMILY ❑MOBILE HOME POOL/SPA ❑SIGN
SUBTYPE: []ADDITION ❑ALTERATION [-]DEMOLITION ❑ELECTRICAL ❑MECHANICAL
❑NEW ❑PLUMBING ElRpE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK ( l r 'i qFS f C
a�ta In in
PROJECT ADDRESS (9 � s -
ASSESSOR'S PARCEL NUMBER LOT TRACT
OWNERNAME �(n
ADDRESS S Lie P p
PHONE EMAIL
APPLICANT NAME e -'e t
ADDRESS a I S CJ ±-, VVI "pre,
PHONE � � � �-. �j 7 EMAIL
CONTRACTOR'S NAME C C OWNER BUILDER? DYESIZINO
BUSINESS NAME
ADDRESS �..�
PHONE ,, 3'7 EMAIL
CONTRACTOR'S STATE LIC NUMBER P Yq 7 a g LICENSE CLASSIFICATION
VALUATION$ CT(`f __ SO FT / L SQ FT
APPLICANT'S SIGNATURE DATE
CITY STAFF USE ONLY
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAID AMOUNT
AMOUNT -CASH O+CHECK# 0CREDITCARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT 0CASH -CHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED C YES 0 NO DL NUMBER NOTARIZED LETTER 0 YES 0 NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.citvofinenifee.us Inspection Request Line 951-245-6213
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