PMT15-02452 City of Menifee Permit No.: PMT15-02452
29714 HAUN RD. Type: Mobile Home
<ACCEL/� MENIFEE, CA 92586
........
°"-` MENIFEE Date Issued: 1 0/1 61201 5
PERMIT
Site Address: 28915 EURTON RD, MENIFEE, CA 92584 Parcel Number: 372-100-012
Construction Cost: $4,500.00
Existing Use: Proposed Use:
Description of INSTALL FOR NEW 268"x 56'MANUFACTURED HOME ON PERM FOUNDATION AS 2ND UNIT
Work:
Owner Contractor
MARK&TINA NICKERSON LANIK ENTERPRISES INC
28915 EURTON ROAD P O BOX 891416
MENIFEE, CA 92584 TEMECULA, CA 92589
Applicant Phone:9516767114
GORDON LANIK License Number:458947
LANIK ENTERPRISES INC
PO BOX891416
TEMECULA, CA 92589
Fee Description ON Amount($)
Manufactured Install 1 240.72
Permit Fee 1 27.00
$267.72
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_aldg_Permit_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION ❑ 1 am exempt from licensure under the Contractors'State License Law for the
1 hereby affirm under penalty or perjury that I am licensed under provisions of following reason:
Chapter 9(commencing with section 7000)of Division 3 of the Business and By my signature below I acknowledge that,except for my personal residence in
Professions Cade and my license is in full force and effect. which I must have resided for at least one year prior to completion of
License Class A,9,Cn6�Z Lice se No. � 1`7 improvements covered by this permit, I cannot legally sell a structure that I have
built as an owner-building if it has not been constructed in its entire b licensed
Expires 9` r ^/7 Signature 9 entirety Y
67
contractors. I understand that a copy of the applicable law, Section 7044 of the
WORKERS'COMPENSATION DECLARATION Business and Professions Code,is available upon request when this application is
submitted or at the following Web site:
w❑ I hereby ill under penalty of perjury one the following declarations: hftp://v .leginfo.ca.aov/calaw.htmi.
I have and will maintain a certificate of consentt of self-insure for workers
compensation,issued by the Director of Industrial Relations as provided for by Date
Section 3700 of the Labor Code,for the performance of work for which this
permit is issued. Property Owner or Authorized Agent
Policy# ❑ By my Signature below, I certify to each of the following: I am the property
O� I have and will maintain workers' compensation insurance, as required by owner or authorized to act on the property owner's behalf. I have read this
section 3700 of the Labor Code, for the performance of the work for which this application and the information I have provided is cored. I agree to comply
permit is issued.My workers'compensation insurance carrier and policy number are: 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-
carrier��,p6.oy� CAP%O ident' dpro ery for the' spection urposes.
Policy#AW'<��IO7Z 9 Expires �� �'�� Date
Property OwnerofAuthorized Agent
(This section need Dot be completed if the permit is for City Business License# ��� 2-.3 9
one-hundred dollars($100)or less) ty
❑ I certify that in the performance of the work for which this permit is issued,1 HAZARDOUS MATERIAL DECLARATION
shall not employ any persons in any manner so as to become subject to the Will the applicant or future building occupant handle hazardous material or a
workers'compensation laws of California, and agree that if I should become mixture containing a hazardous material equal to or greater that the
subject to the workers compensation provisions of Section 3700 of the Labor amounts specified on the Hazardous Materials Information Guide?
Code,I shall forthwith comply with those provisions. DYES V<O
Applicant; Date; Will the intended use of the building by the applicant or future building
occupant require a permit for the construction or modification from South
WARNING: FAILURE TO SECURE WORKERS' Coast Air Quality Management District(SCAQMD)?See permitting checklist
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL for guidelines
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND DYES CKNO
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, Will the proposed building or modified facility be within 1000 feet of the outer
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE boundary of a school?
LABOR CODE, INTEREST,AND ATTORNEYS FEES DYES B-NO
CONSTRUCTION LENDING AGENCY I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm that under the penalty of perjury there is a construction lending permitting checklist.I understand my requirements under the State of
agency for the performance of the work which this permit is issued (Section California Health&Safety Code,Section 25505 and 25534 concerning
3097 Civil Code) hazardous terial reporting.
OWNER BUILDER DECLARATIONS DYES No'NO _ _
I hereby affirm under penalty of perjury that I am exempt from the Contractor's Date/0-746 f
License Law for the reason(s)indicated below by the checkmark(s)I have placed PROPERTY OWN R AUTHORIZED AGENT
next to the applicable items)(Section 7031.5. Business and Professions Code:
Any city or county that requires a permit to construct, alter, improve, demolish, EPA RENOVATION-REPAIR AND PAINTING fRRP1
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 The EPA Renovation,Repair and Painting(RRP)Rule requires contractors
provisions of the Contractor's State License Law (Chapter 9(commencing with receiving compensation for most work that disturbs paint in a pre-1978
Section 7000)of Division 3 of the Business and Professions Code)or that he or residence or childcare facility to be RRP-certified firms and comply with
she is exempt from Iicensure and the basis for the alleged exemption. Any required practices.This includes rental properly owners and property
Violation of Section 7031.5 by any Applicant for a permit subjects the applicant to managers who do the paint-disturbing work themselves or through their
a civil penalty of not more than($500).) employees.For more information about EPKs Renovation Program visit:
❑ I, as owner of the roe www.epa.govAead or contact the National Lead Information Center at
property,rty, or my employees with wages as their sole 1-800-424-LEAD(5323).
compensation,will do( )all of or( ) porting of the work,and the structure is
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 ❑An EPA Lead-Safe Certified Renovator will be responsible for this project
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale.If,however, Certified Firm Name:
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 Firm Certification No.:
purpose of sale).
❑ 1, as owner of the property an exclusively contracting with licensed ❑No EPA Lead-Safe Certified Firm is required for this project because:
contractors to construct the project(Section 7044, Business and Professions
Code:The Contractors License Law does not apply to an owner of a property
who builds or improves thereon, and who contracts for the projects with a
licensed contractor(s)pursuant to the Contractors State License Law). If your project does not comply with EPA RRP rule please fill out the RRP
Acknowledgement.
AJ do
SING
OV 19+y STATE Of CALIFORNIA NUMBER:
I ". BUSINESS,TRANSPORTATION AND HOUSING AGENCY
n 711 man DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
O u DIVISION OF DES AND STANDARDS
MANUFACTURED HOUSING PROGRAM
MANUFACTURER CERTIFICATE OF ORIGIN
❑ CHECK IF THIS IS A DUPLICATE MCO-ENTER ORIGINAL MCO NO.
MANUFACTURED HOME OR MULTIFAMILY MANUFACTURED HOUSING NUMBER OF
Q SFD(SINGLE FAMILY DWELLING) ❑ MFMH(MULTIFAMILY MANUFACTURED HOUSING) TRANSPORTABLE SECTIONS
COMMERCIAL MODULAR:
OCCUPANCYGROUP
MANUFACTURER NAME: MANUFACTURER LICENSE NUMBER:
CHAMPION HOME BUILDERS, INC. 1218438
MANUFACTURER ADDRESS: SUGGESTED RETAIL PRICE:
299 NORTH SMITH, CORONA, CA 92880 N/A
Street Ci State (zip)
MANUFACTURER TRADE NAME MODEL NAME AND/OR NUMBER: DATE OF MANUFACTURE:
SILVERCREST I BRADFORD 10/07/2015
NAME OF DEALER OR TRANSFEREE(OWNERSHIP TRANSFERRED TO): CALIFORNIA DEALER NUMBER OR DATE OF TRANSFER:
TRANSFEREE DESIGNATION: 10/07/2015
AAAMERICAN PACIFIC MFG HOMES 92676
DEALER OR TRANSFEREE ADDRESS: ,
streets BENT AVENUE, SAN MARCOS, CA 9207ei Stare Z
INVENTORY CREDITOR NAME:
INVENTORY CREDITOR ADDRESS:
street (City) Slate ZI
SECTION LENGTH WIDTH WEIGHT
It-BI MANUFACTURER SERIAL NUMBER HCD INSIGNIA OR HUD LABEL NUMBER dNCHES) (INCHES) (POUNDS)
1 176-OOF-H-A100346A NTA 1684325 672 160 32,506
176-00E-H-A100346B NTA 1684326 672 160 31,806
TRANSPORTER NAME:
R9K
TRANSPORTER ADDRESS:
10 '7 V11. STOWELL RD, SANTA MARIA, CA 93458
(Street) (City) (State) (ZIP)
DESTINATION FOR UNIT DESCRIBED ABOVE
MARK NICKERSON, 28915 EURTON LANE, MENIFEE, CA 92584
NAME treat q Stale (b
I cer8fy under penalty of perjury under the laws of the State of California that the above fat95 are true and wnect.
10/07/2015 CORONA, RIVERSIDE, CALIFORNIA
Executed on at
(Dale) (City) (County) (State)
SIGNATURE OF AUTHORIZED AGENT:
DISTRIBUTION: ORIGINAL��pp11 ) FOR ARD O THE INVENTORY CREDITOR,UNLESS THERE IS NONE,THEN FORWARD TO THE PURCHASER(DEALER OR TRANSFEREE).
COPY 1(WHITE) FORWARD TO THE DEPARTMENT AT P.O.BOX IBM.SACRAMENTO.CA 95812-1828,WITHIN FIVE(5)DAYS OF RELEASE
COPY 2(YELLOW) DELIVER TO THE TRANSPORTER TO ACCOMPANY THE UNIT TO ITS DESTINATION.
COPY 3(GOLDENROD) TO BE RETAINED BY THE MANUFACTURER.
HCD 483.0-Side 1-(Rev.01112)