PMT15-02023 City of Menifee Permit No.: PMTIB-02023 1
''•�•-.�, 29714 HAUN RD.
' CCEL MENIFEE, CA 92586 Type: Residential Plumbing
s asw . MENIFEE Date Issued: 07/16/2015
I
I
PERMIT
Site Address: 28930 LAKE FORK DR, MENIFEE, CA Parcel Number: 340-190-021
92584 Construction Cost: $800.00
Existing Use: Proposed Use:
Description of REPLACE EXISTING WATER HEATER, SAME SIZE AND LOCATION
Work:
Owner Contractor
KEN CIBOCH ALL STAR WATER HEATERS INC
28930 LAKE FORK DRIVE 30300 PUERTO VALLARTA WAY
MENIFEE, CA 92584 MENIFEE, CA 92584 -
Applicant Phone: 9513010067
SIERRA SPRAGUE License Number: 812894
ALL STAR WATER HEATERS INC
30300 PUERTO VALLARTA WAY
MENIFEE, CA 92584
Fee Description Qty Amount
e a as a 830 >
Building Permit Issuance 1 27.00
E • : a•0
$111.00
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
1
1
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 protect(Section 7044, Business and Professions
Professions Code and my license is full force and effect. Code:The Contractor's License Law does not apply to an owner of.a property
License Cie s License No. who builds or Improves thereon, and who contracts for the projects with a
Expires_1 I ,30 Signature Ilcensed contractor(s)pursuant to the Contractors State License Law).
WORKERS'COMPENSATIOND CLA ATION
❑ 1 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 permit Issued. Improvements covered by this permit, I cannot legally sell a structure that have
Policy ! bullt 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
section 3700 of the Labor Code, for the performance of the work for which this submitted or at the following Web site:hfto://www.leQlnfo.ca.gov/calaw.htrni,
permit Is Issued,My workers'compensation Insurance carrier and policy number are:
n/ Property Owner or Authorized gent
Carrier Z4 E Date
Expires ,,u //S- Policy# M/ c 54PD'N 44
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. 1 have read this
(This section need=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-
❑ 1 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 S
subject to the workers'compensation provisions of Section 3700 of the Labor property ner Authorized Agent Date
Code, I shall forthwith comply with those provisions.
City Business License# /J,4S'O/S
Date; �/j� �i.s Applicant;
WARNING: FAILURE TO Ec .E WORKERS' HAZARDOUS MATERIAL DECLARATION
COMPENSATION COVERAGE IS UNLA FUL, AND $HALT,
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 HANDLEA HAZARDOUS MATERIAL ORA
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 3097 Civil Code) WILL THE INTENDED USE OF THE BUILDING BY THE
APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE
Lender's Name []YES 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 reasons)indicated below by the checkmark(s)I have placed []YES 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 orshe 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 icensure 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 p NO UNDER THE STATE OF CALIFORNIA HEALTH AND SAFETY
a civil penalty of not more than($500).) CODE SECTION 25505 25533 AND 25534 CONCERNING
❑ I, as owner of the property, or my employees with wages as their sole HAZAdDOUS MATERIAL IAEPOR1ING.
compensation, will do ( )all of or ( ) porting of the work, and the structure Is PROPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale, (Section 7044, Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property X
who, through employees or personal effort, builds or Improves the property, -
provided that the improvements are not intended or offered for sale. If,however,
the building or Improvement Is sold within one year of completion, the Owner-
Builder will have the burden of proving that It was not built or Improved for the
purpose of sale).
64DIN &SAFETY PERM
rife
DATE 'J S PERMIT/PLAN CHECK NUMBER -�
TYPE: O COMMERCIAL ✓RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA 0 SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW ✓ PLUMBING O RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK Replace existing water heater. Same Size and location.
PROJECTADDRESS 28930 Lake Fork Dr. Qa5l?4u
ASSESSOR'S PARCEL NUMBER ':�LAO, IaQ -m, LOT TRACT
OWNER NAME Ken Ciboch
ADDRESS 28930 Lake Fork Dr.
PHONE 951-679-3736 EMAIL
APPLICANT NAME Sierra S ra Ue
ADDRESS 30300 Puerta Vallarta
PHONE 951-301-0067 EMAIL allstar.sierra mail.com
CONTRACTOR'S NAME Sierra Sprague OWNERBUILDERi 0YESjW
BUSINESS NAME All Star Water Heaters
ADDRESS 30300 Puerta Vallarta Way
PHONE 951-301-0067 EMAIL allstar.sierra@gmail.com
tONTRACI`OR'S STATE UC NUMBER 812894 LICENSE CLASSIFICATION C36
VALUATION$ -800.00 SQ FT L SQ FT
APPLICANT'S SIGNATURE DATE.
DEPARTMENT DISTRIBUTION CItY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE I GREEN SMIP. X
INYOICE PAID:AMOUNT
AMOUNT OCASH )CHECK# C+CREDIT CARD VISA/MC
PLAN CHECK FEES PAID.AMOUNT O CASH 0 CHECK# 0 CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED O YES 0 NO DL NUMBER NOTARIZED LETTER 0 YES 0 NO
City of Menifee Sl+ildL:g E.Safety Deportment 29714 H(2urr Rd. Menifee, CA925869>1-672-6777
www.cityof,,T)eni/eaus lnspecEan Request Line 951-246-6213
`. .4
zM
ro " ►!1
CO
'no CA
w
w -Pi a y a m A
O
3 7 3 N AOQ
o - a o
ea
tr
m
o
rp a
cu ry i.F id v
17, „
ro $ 2
Li P a p
a „ m a cr C +C
T T C N Q N ~
P ('f ¢ �3
P c
V GJ n G ry. $ �y w T W N a N
Al
F 9
�i ro » p1 o m 20
�? m
P
4vc
am rn
�' � a " F% _
w �
i
O
c ro -p
m J MI
CD
SD
�.
Y" ' t
�@ t Im
a r�. rp @� a M ro
.Ap
3 ❑: Sa. A' IU pJP�1 # .m`i +ski q 'yy .� +g91j yy
ro x c .a CLoa
Nil
.&ninaic° m � ro
W " lN
a rn
r.
17
Ln
LO IA'
d " 0 c
Q rn
m �G,
m