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PMT15-01930
1 1 City of Menifee Permit No.: PMT15-01930 29714 HAUN RD.MENIFEE, CA Type: Commercial Alteration - j MENIFEE Date Issued: 07108/2015 1 : PERMIT j Site Address: 27682 HWY 74, MENIFEE, CA 92585 Parcel Number: 329-211-030 Construction Cost: $0.00 Existing Use: Retail Proposed Use: Description of HOURLY INSPECTION FOR CERTIFICATE OF OCCUPANCY FOR"MEDI CALI TOBACCO SHOP" Work: Owner Contractor LYDIA CARMEN ROJAS 27682 HWY 74 MENIFEE, CA 92585 Applicant License Number: IBRAHIM RAHMAN MEDI CALI TOBACCO SHOP 2131 N PERRIS BLVD STE C4 PERRIS, CA 92571 _ Phone: 9519286368 Fee Description f3yt Amount 1$1 Inspections not specified 129 129,07 $166.07 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 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 ❑ I am 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,leqinfo.ca,Qov/calaw.html. permit is issued.My workers'compensation Insurance carrier and policy number are: Carrier Property Owner or Authorized Agent Date Expires Policy# Name of Agent Phone# Li 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 out orize 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 identified,aproy r the inspe pu doses. 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 `7 subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Property Owner or Authorized Agent Date 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, EYES OCCUPANT HANDLEA HAZARDOUS MATERIAL ORA DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE MIXTURE CONTAINING A HAZARDOUS MATERIAL LABOR CODE, INTEREST,AND ATTORNEYS FEES ONO 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 AYES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION Lender's Address FROM THE SOUTH COAST AIR QUALITY MANAGEMENT ❑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 reason(s)indicated below by the checkmark(s)I have placed EYES 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 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 EYES 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 property, or my employees with wages as their sole HAZARDOUS MATERIAL REPOR7 ING. 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 properly 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). CERTIFICATE OF OCCUPANCY APPLICATION city 01 Building & Safety DePt' JUL ° B 2015 -Menifee Received PHTI5 ' 0(9:50 DATE __ �^^ /� L._1 PERMIT NUMBER I BUSINESS NAMEfr eP t' YGSu 'kt�ALb0) Sko TYPE OF BUSINESS -roV)Cm '��11�70 ADDRESS 2 k NAME OF BUSINESS OWNER(S) p `C� l urn �wlnevV\r r ADDRESS(IF DIFFERENTT FROM ABOVE) L p Al�Pir I' G L �/ Sl 7c� �// PHONE I�c � else) - ©95Z EMAIL , �✓LC,/Z ! L OWNER OF BUILDING C/i fi ^4 vv C Y4(1'ek l & 16,-S ADDRESS.'7 4- _�;? 2 /z S ZLf k PHONE -A L.2 EMAIL DESCRIBE EXACT USE OF BUILDING: fiOLJc.ee V S PREVIOUS USE OF BUILDING/SUITE 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 of the ertificate of Occupancy. I, hereby agree to comply with the above-described terms in this Application for Certificate of Occ ancy. DATE —7/ —? APPLICANT CITY STAFF USE ONLY (PLEASE SIGN AND DATE IFAPPROVED) BUS LICENSE DATE ENGINEERING DATE BUS LIC.NUMBER FIRE DATE PLANNING DATE EM WD DATE HEALTH DEPT DATE BUILDING DATE REMARKS Cily of Menefee 6w1d, ?g & SnJely 0apaitment29714 Haan Rd N' rmfee, CA 92586 9-51 672-6777 www.cityo(menifee.Lis Inspection Request Line OF OCCUPANCY TENANT DISCLOSURE FORM City of Menifee Building & Safety Dept. JUL 0 8 2015 Menifee Pllfif DATE Received PERMIT NUMBER ADDRESS 2_ 7 6 9 z } MJ3WD BUSINESS NAME d Ll� da��GCp' INTENDED BUSINESS USE IS THIS A NEW BUSINESS IN THE CITY OF MENIFEE? YES NO (CIRCLE ONE) ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? YES NO (CIRCLE ONE) C � J IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? NO (CIRCLE ONE) SQUARE FOOTAGE �T� NUMBER OF EMPLOYEES NUMBER AND LOCATION OF RESTROOM FACILITIES "r LIST ANY TOXIC 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 05' 9" HIGH? YES O (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 e� / SIGNATURE DATE PRINTNAME TENANT / OWNER / CONTRACTOR / ARCHITECT / ENGINEER (CIRCLE ONE) CITY STAFF USE ONLY OCCUPANCY GRP TYPE OF CONST STAFF INITIALS City of Menifee Building& Safety Depot tment29714 Houn Rd. Menifee, CA 92556 951-672-6717 www.cityofinenifee.us Inspection Request Line 951-246-6213