PMT15-01736 City of Menifee Permit No.: PMT15-01736
29714 HAUN RD. Type: Commercial Alteration
q:XCX:XLA--!,PMENIFEE, CA 92586
MENIFEE Date Issued: 0 612 3/2 01 5
PERMIT
Site Address: 29800 BRADLEY RD, Suite# 102, Parcel Number: 336-180-011
MENIFEE, CA 92586 Construction Cost: $0.00
Existing Use: Proposed Use:
Description of HOURLY INSPECTION FOR C OF 0"PSYCHIC OF MENIFEE"
Work:
Owner Contractor
BRADLEY BUSINESS CENTER
310 VIA VERA CRUZ
SUITE 202
Applicant License Number:
MENIFEE, CA
Fee Description Rill. Amount M
UII e mlf�ssuce . e 4",
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 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 slated,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
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 ❑ lam exempt from licensure under the Contractors'State License Law for the
❑ 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. built as an owner-building if it has not been constructed in its entirety by licensed
Policy# 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 leainfo pa,gov/calaw.html.
permit is issued.My workers'compensation insurance carrier and policy number are:
Property Owner or Authorized Agent Date
Carrier
Expires Policy#
❑ 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 tk'
(This section need not be completed if the permit is for application and the information I have provided is corrc=' : ..s,ee 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-
El I certify that in the performance of the work for which this permit is issued,I identified property 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 agree that if I should become C1PXG.U-� rP_
subject to the workers'compensation provisions of Section 3700 of the Labor Property Own di or Authorized Agent
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, AYES 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 Li NO EQUAL TO OR GREATER THAN THE AMOUNTS
CONSTRUCTION LENDING AGENCY 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
FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
Lender's Address ❑NO DISTRICT(SCAQMD) SEE PERMITTING CHECKLIST FOR
GUIDE LINES
OWNER BUILDER DECLARATIONS PRINT NAME:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the reason(s)indicated below by the checkmark(s)I have placed AYES 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, ❑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 I HAVE READ THE HAZARDOUS MATERIAL
provisions of the Contractor's Slate License Law(Chapter 9 (commencing with
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 ❑NO UNDER THE STATE OF CALIFORNIA HEALTH AND SAFETY
a civil penalty of not more than($500).) HOODAEI2DO CTION 255L6 25533EPOkf AND
25534 CONCERNING
❑ I, 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 PROPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code; X
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).
CERTIFICA E OF OCCUPANCY APPLICATION
cz9_Q �15� U�11 gloo
'`Menifee
i Ave : 3aw •100- ot�
DATE V UY'L2 —I- ( S PERMITNUMBER Pl��15 ' o �1�Q
BUSINESSNAME P6W6h1C 04 e7l-en,'Fee TYPEOFBUSINESS f/S(ijtl jC_
ADDRESS I J ro- a e w Yyt el 4e ( � q Sv 4-G 1 D 7
NAME OF BUSINESS OWNER(S) ((I ',I A r�cn „ �I / /1
ADDRESS(IF DIFFERENT FROM ABOVE) 7, x 7-7 n 1't l' lA n 1' zn Ter, ez , 'I25,S"y
PHONE G s 1- 30 )-011 11 1 EMAIL M.e A en Ps (� C VI (0- cw 1 • nortj
OWNER OF BUILDING
' V1-CJ1P�J �V5inI2 5 CP/1.j ( LLC
ADDRESS .J j� V I /� �1 e IrCA 0'U 7 �v n M (C y ` �' CL 9 7 0-7 r6 02
PHONE 2 6 0 - y -7 l - l q 9 EMAIL
DESCRIBE EXACT USE OF BUILDING: P 5u C VI , C TZ ec l„y.i
PREVIOUS USE OF BUILDING/SUITE I \ u I. COL 0
APPLICANT ACKNOWLEDGEMENT
Applicant agrees that the Certificate of Occupancy shall be posted in a conspicuous location, and will operate subject
to the City's issuance
/ofrthe Certificate of Occupancy.
I, " (Ckw(t1 A4 A441S hereby agree to comply with the above-described terms in this
Applic tion for Certificate of Occupancy.
A A=a=nw� DATE-
APPLICANT
CITY STAFF USE ONLY (PLEASE SIGN AND DATE IF APPROVED)
BUS LICENSE DATE ENGINEERING DATE
BUS LIC.NUM R i FIRE DATE
l
PLANNIN .� DATE � EMWD DATE
HEALTH DEPT DATE BUILDING DATE
REMARKS
City of Menifee Building&Safety Deportment 297.14 Honn Rd. Menefee, CA 92586 951-672-6777
www.city0finenifee.us Inspection Request Line
�a
If
ADDRESS G-q 00 Gf l oVAd rkuj /ice Y crn
BUSINESS NAME % o F
INTENDED BUSINESS USE
IS THIS A NEW BUSINESS IN THE CITY OF MENIFEE? YES DO (CIRCLE ONE)
ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? YES �N) (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? (YES NO (CIRCLE ONE)
SQUARE FOOTAGE ,a a 0 A
NUMBER OF EMPLOYEES �.
NUMBER AND LOCATION OF RESTROOM FACILITIES
LIST ANYTOXIC CHEMICALS, FLAMMABLE/COMBUSTIBLE LIQUIDS OR GASES USED OR STORED WITH
MSDS SHEETS AND QUANTITIES OF EACH BELOW OR ON A SEPARATE ATTACHED SHEET(S):
ARE YOU MAKING ANY IMPROVEMENT TO THE SUITE OR BUILDING OTHER THAN PAINTING,
PAPERING, FLOOR COVERING, MOVABLE CASES, SHELVING OR PARTITIONS NOT OVER 5' 9" HIGH?
YES (NO
,•' (CIRCLE ONE)
• APPLICANT SHALL OBTAIN ALL REQUIRED CLEARANCES AND/OR APPROVALS FROM THE
APPROPRIATE WATER DISTRICT AND FIRE DEPARTMENT PRIOR TO ISSUANCE OF ANY
BUILDING PERMITS
SIGNATURE ey�!'i01VI/ /q�111� DATE
PRINT NAME A M A df4 w
T NE ANT / OWNER J CONTRACTOR / ARCHITECT J ENGINEER (CIRCLE ONE)
FOR CITY STAFF PERMIT NUMBER
OGGUPANCY GRP TYPE OF CONST I STAFF INITIALS
City of Menifee Building&Safety Department 29714 PIULIn Rd, Menifee, CA 92566 951-672-6777
www.dtyofinenifee,us Inspection Request line 951-246-621.3