PMT15-02881 1
City of Menifee Permit No.: PMT16-02881
29714 HAUN RD. Type: Residential Electrical
' CCE MENIFEE, CA 92586
MENIFEE Date Issued: 0 911 6/2 0 1 6
P E R M 11
i
i�
Site Address: 30273 SHORELINE DR, MENIFEE, CA Parcel Number: 364-043-048
i
92584 Construction Cost: $1,000.00
Existing Use: Proposed Use:
Description of MAIN PANEL UPGRADE 200A
Work:
Owner Contractor
MICHAEL KASSENS
30273 SHORELINE DRIVE
MENIFEE, CA 92584
Applicant License Number:
MICHAEL KASSENS
30273 SHORELINE DRIVE
MENIFEE, CA 92584 -
Phone: 9515815704
Fee Description Qy Amount f$1
�Serwces SWltchboards�Contrpl Celifers& Pan fs-';`�'' ^"{��3 d ��1�'e�`'?"f`;k`'�t"°�i `��1�i6 00
Building Permit Issuance 1 27.00
•GRE�N SEE y�Sr g��w�Fi^t�g."E, �.e+�" sn ��` l� dx 1 �o 'rzr"i1 t=��"`�yr*r,,�epS.-"� �OO
� 1__...,._ u.ahshta..«..xa��Ax.,�asv^x ...._S?.F �.w&s...u.s.*s4..o..*.vtn.. ✓3 T,fi.,e...w s:,+c
General Plan Maintenance Fee-Electrical 1 5.80
$149.80
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 ❑ 1 am exempt from licensure under the Contractors'State License Law for the
following reason:
I hereby affirm under penalty or perjury that I am licensed under provisions of
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 Code 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 License No. improvements covered by this permit, I cannot legally sell a structure that I have
Expires Signature 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
WORKERS'COMPENSATION DECLARATION Business and Professions Code,is available upon request when this application is
submitted or at the following Web site:
❑ I hereby affirm under penalty of perjury one of the following declarations: http://www.leciinfo.ca.gov/calaw.html.
I have and will maintain a certificate of consent of self-insure for workers' �•� p
compensation, issued by the Director of Industrial Relations as provided for by /��k&,ta Date
Section 3700 of the Labor Code, for the performance of work for which this —ZJ
permit is issued. Property Owner or Authorized Agent
Policy# )�By my Signature below, I certify to each of the following: I am the property
❑ 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 correct. 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 identified property or(the inspection ppuurrposes.
Policy# Expires M kilo- " Date—
Property Owner or A thorized Agent
(This section need not be completed if the permit is for City Business License#
one-hundred dollars($100)or less)
HAZARDOUS MATERIAL DECLARATION
❑ 1 certify that in the performance of the work for which this permit is issued, I
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. [I YES ❑ NO
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 El YES ❑ NO
_ 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 ❑YES ❑ 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 material reporting.
OWNER BUILDER DECLARATIONS DYES ❑ NO
I hereby affirm under penalty of perjury that I am exempt from the Contractor's Date
— License Law forthe reason(s)indicated below by the checkmark(s)I have placed PROPERTY OWNER OR 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(RRP)
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 licensure and the basis for the alleged exemption. Any required practices.This includes rental property 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 EPA's Renovation Program visit:
www.epa.gov/lead or contact the National Lead Information Center at
I, as owner of the property, or my employees with wages as their sole 1-800-424-LEAD(5323).
compensation, will do K)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).
❑ I, 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 Contractor's 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.
q a » ) • 4 A i r y y � III
Y
Ii
DATE cj PERMIT/PLAN CHECK NUMBER Q
TYPE: ❑COMMERCIAL ❑✓ RESIDENTIAL MULTI-FAMILY ❑MOBILEHOME ❑POOL/SPA ❑SIGN
SUBTYPE: ❑ADDITION ❑ALTERATION ❑DEMOLITION ELECTRICAL ❑MECHANICAL
❑NEW ❑PLUMBING ❑RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK Change out existing Service Panel Main to a 200A Square D panel in preparation for Solar
PROJECT ADDRESS 30273 Shoreline Dr. Menifee CA 92584
ASSESSOR'S PARCEL NUMBER 364-043-048 LOT TRACT Bulldl' 9 & Safety apt.
PROPERTY OWNER'S NAME Michael&Rachel Kassens EP 20
ADDRESS 30273 Shoreline Dr. Menifee CA 92584
PHONE (951)581-5704 EMAIL michaelkassens@yahoo.com —ec d
APPLICANT NAME Michael Kassens
ADDRESS 30273 Shoreline Dr. Menifee CA 92584
PHONE (951)581-5704 EMAIL michaelkassens@yahoo.com
CONTRACTOR'S NAME OWNERBUILDER? AYES❑NO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ $ 1,000.00 SO FT LSO FT
APPLICANT'S SIGNATURE DATE 0 911 6/20 1 5
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER^
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP x
INVOICE
AMOUNT PAID AMOUNT +.::-CASH '.)CHECK H CREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT C CASH CHECK# C%CREDITCARD VISA/MC
OWNER BUILDER VERIFIED ",YES i1 NO DL NUMBER NOTARIZED LETTER C YES NO
NOTICE • PROPERTY OWNER
City of Menifee
Building & Safety Dept,
MenifeeAdi SEP 16 2015
BEFORE A BUILDING PERMIT CAN BE ISSUED,THIS FORM MUST BE COMPLETED AND SIGNED BY THRenaVved
OWNER AND RETURNED TO THE CITY OF MENIFEE. IF THE PROPERTY OWNER IS NOT PRESENT TO THE SIGN THE
BUILDING PERMIT, PROPERTY OWNER'S SIGNATURE MUST BE NOTARIZED
Dear Property Owner,
An application for a building permit has been submitted in your name, listing yourself as the builder of the property
improvements specified at 30Z7 ;Atyre_l Jey� D r ✓hell Cr -
The City of Menifee is providing you with an Owner-Builder Acknowledgement and Information Verification form to
make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner-Builder.
The City of Menifee will not issue a building permit until you have read, initialed your understanding of each provision,
signed and returned this form to us at our official address indicated.An agent of the owner cannot execute this notice
unless you,the property owner, obtain the prior approval of the City of Menifee.
Please read and initial each statement below to signify you understand or verify this information:
I understand a frequent practice of unlicensed persons Is to have the property owner obtain an"Owner-Builder"building permitthat
erroneously implies that the property owner is providing his or her own labor and material personally.I,as an Owner—Builder,may be
held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while
working on my property.My homeowner's insurance may not provide coverage for those injuries to workers on my property.
I understand building permits are not required to be signed by property owners unless they are responsible forthe construction and are
not hiring a licensed Contractor to assume this responsibility.
I understand as an Owner-Builder that I am the responsible party of records on the permit.I understand that I may protect myself from
MAK potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own.
I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and
rh3K contracts.
I understand if I employ or otherwise engage or otherwise engage any persons,other than California licensed Contractors,and the total
value of my construction is at least five hundred dollars($500),including labor and materials,I may be considered an"employer"under
ji(n Tj� state and federal law.
I understand if I am an"employer"under state and federal law,I must register with the state and federal government,withhold payroll
taxes,provide worker's compensation disability insurance,and contribute to unemployment compensation for each"employee".I also
S� understand my failure to abide by these laws may subject me to serious financial risk.
I understand under California Contractor's State License Law,an Owner-Builder who builds single-family structures cannot legally build
them with the intent to offer them for sale,unless all work is performed by licensed subcontractors and the number of structures does
J� not exceed four within any calendar year,or all of the work is performed under contract with a licensed general building Contractor.
I understand as an Owner-Builder if I sell the property for which this permit issued,I may be held liable for any financial or personal
M 7k injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship of materials.
I understand I may obtain more information regarding my obligations as an"employer"from the Internal Revenue Service,the United
States Small Business Administration,the California Department of Benefit Payments,and the California Division of Industrial Accidents.
I also understand I may contact the California Contractor's State License Board(CSLB)at 1-800-321-2752 or www.csib.ca.gov for more
(�information about licensed contractors.
City of Menifee Building& Safety 0epartment29714 Noun Rd. Menifee, CA 92586951-672-6777 �.
www.cityofinenifee.us Inspection Request Line
NOTICE • PROPERTY OWNER
1
I am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that I am the party legally and 4
financially responsible for proposed construction activity at the following address:
(� I agree that,as the party legally responsible for this proposed construction activity.I will abide by all applicable laws and requirements
that govern Owner-Builders as well as employers.
I agree to notify the issuer of this form immediately of any additions,deletions,or changes to any of the information I have provided on
this form.
Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not
! have a license,the Contractor's State License Board may be unable to assist you with any financial loss you may
sustain as a result of a complaint.Your only remedy against unlicensed Contractors may be in civil court. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured
while working on your property,you may be held liable for damages. If you obtain a permit as Owner-Builder and
wish to hire Contractors,you will be responsible for verifying whether or not those Contractors are properly licensed
and the status of their workers compensation coverage.
PLEASE NOTE: If the property owner is not present to sign the building permit documents you must provide the
following documentation:
1. Proof of Identification (Picture ID, Driver's License,etc.)
2. Proof of Ownership(Grant Deed, Property Tax Statement-of recent transfer of ownership)
3. If a Trust,Trust information showing Trustee
4. If Corporation, LLC or Partnership—information verifying President and or Authorized Representative
5. If Agent for the Owner—all of the above plus an "Authorization for Agent to Act on Property Owner's Behalf"
for notarized by the Property Owner is required n Lp' o
Signature of Property Owner Y�/� Q, L'�rrt�' Date /
(must be notarized if owner is not present at time of building perm issuance)
I declare under penalty of perjury according to the laws of the State of California that the foregoing is true and
correct, and that this declaration was executed on at
(Date) (Place)
Print Full Name of Notary Signature
Place Notary Seal Here:
Please return to City of Menifee Building&Safety Department
City of Menifee Building&Safety Department 29714 HQUn Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line