PMT15-03153 City of Menifee Permit No.: PMT16-03153
29714 HAUN RD.
4ACCEL_A MENIFEE, CA 92586 Type: Residential Re-Roof
MENIFEE Date Issued: 1 010 9/2 01 5
PERMIT
Site Address: 28763 CARMEL RD, MENIFEE, CA 92586 Parcel Number: 337-215-019
Construction Cost: $10,200.00
Existing Use: Proposed Use:
Description of REMOVE&REROOF WASHPHALT FIBERGLASS DIMENSIONAL SHINGLES,`•NOTA COOL
Work: ROOF-INSPECTOR PLEASE VERIFY R-38INSULATION"
Owner Contractor
JOHN ROUSSOPULOS GARRETT CONTRACTING SERVICES
6 DELLA CAVA LN 288 VIA DE AMO
LAKE ELSINORE. CA 92532 FALLBROOK, CA 92028
Applicant Phone:6266654384
RICK GARRETT License Number:536485
GARRETT CONTRACTING SERVICES
288 VIA DE AMO
FALLBROOK, CA 92028
Fee Description O_yt Amount ISl
Building Permit Issuance 1 27.00=.
Inspections not specified 98 98.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Building 1 4.90
$130.90
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 Templatespi Page 1 of 1
City Of Menifee
LICENSED DECLARATION ❑ lam exempt from licensure under the Contractors'State License Law for the
I 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 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 Ci 3—Hj c License No. S 3 G AycSr Improvements covered by this permit, I cannot legally sell a structure that I have
Expires D, C . Signature,6-L_ J uilt 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'COMPENSATI ON DECLARATION Business and Professions Code,is available upon request when this application is
submitted or at the following Web site:
❑ 1 hereby affirm under penalty of perjury one the following declarations, httpJ/www.leginfo.ca.gov/calaw.html.
I have and will maintain a certificate of consenttforwo 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
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. 1 agree to comply
permit is issued.My workers'compensation insurance carrier and policy number are: with all applicable city and county ordinances and stale laws relating to building
construction.I authorize representatives of this city or county to enter the above-
Carrier fA-F S i h C / identified property for the inspection purposes.
Policy# lti ttJ 3157s'J'Y'Expires �/71/E Property Owner or Authorized Agent Date
(This section need not be completed if the permit is for City Business License#
one-hundred dollars($100)or less)
❑ 1 certify that in the performance of the work for which this permit is issued,I 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. ❑YES PJO
Applicant ----'Dade; 19I/S` 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 ;FNO
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,�o+f��a school?
LABOR CODE, INTEREST,AND ATTORNEYS FEES DYES XNO
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 NgES ❑NO
I hereby affirm under penalty of perjury that I am exempt from the Contractors —p'—per��� Date
License Law for the reason(s)indicated below by the checkmark(s)I have placed PROPERTY OWNER OR AUTHORIZED AGENT
next to the applicable Rem(s)(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 firths 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( )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 Finn 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
Actmowledcament.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION ; Q
1
Y "1
Menifee `
DATE PERMIT/PLAN CHECK NUMBER
TYPE: C COMMERCIAL ESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW O PLUMBING VRE-ROOF-NUMBER OF SQUARES ajd-
DESCRIPTION OF WORK + voi= A4✓f = ti 4 t
PROJECTADDRESS ,5 /�,Cv911-444FLCRF�D uN cl— t q.2CW
ASSESSOR'S PARCEL NUMBER " /0pa -al .-DO LOT 10(0 TRACT V
OWNER NAME v rt 0V(S cU Pv L vS
ADDRESS G - c. f4 ci )
PHONE / ZA _ �Z� 6,��� EMAIL
APPLICANT NAME •5 /� =[,cw
ADDRESS
PHONE EMAIL
CONTRACTOR'S NAME ¢12>Zr'^jr OWNER BUILDER? O YESeX'NO
BUSINESSNAME ¢ ZtoTl' o TsiAct�nt (r �l1.c.iccrS
ADDRESS A.ST: ck, cI11.02
PHONE /'16•- /96c 'f'3g'Jf- EMAIL
CONTRACTOR'S STATE LIC NUMBER S'3E LICENSE CLASSIFICATION 13 "C3? -H c
VALUATION$ j p0 Z O v SQ FT L SO FT
APPLICANT'S SIGNATURE c l-s�------�DATE vl`7%sT
OTYSTAFFUSEONLY
DEPARTMENT DISTRIBUTION CITYOFME
i NIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN 1� SMIP
INVOICE - PAID AMOUNT
AMOUNT 0CASH 0CHECK# OCREDITCARD VISA/MC
PLAN CHECK FEES PAID AMOUNT O CASH O CHECK It OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building&Safety Department 29714 Haun Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
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ACCWbe CERTIFICATE OF LIABILITY INSURANCE DATE(MMWNYYY)
�/ 0 8/1 212 01 5
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pol(cy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such end°rsement(s).
PRODUCER CONTACT
NAME' LIZBETH RUIZ
A&J Insurance Agency Inc. PHONE FAX
1381 E. Las Tunas Dr.#7 L ' (626)286.3410 ac No:(626)286-6502
E-MAIL
L:m@ajins.com
Gabriel , CA 91776 ADDRESS: a'ins.com
License#: OD10261 INSURERS AFFOROINGCOVERAGE NAICR
INSURERA: Builders and Tradesmens Insurance
nce
INSURED INSURERS:
RICHARD GARRETT
DBA: GARRETT CONTRACTING SERVICES INSURERC:
288 VIA DE AMO INSURERD:
FALLBROOK,CA 92028 INSURERE:
NSURERF:
COVERAGES CERTIFICATE NUMBER: 00026632.17160 REVISION NUMBER: 2
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
�S TYPE OF INSURANCE L9UBR POLICY NUMBER MMNO� MMNCOYYIPY LIM"
GENERAL LIABILITY EACH OCCURRENCE 5
COMMERCVIL GENERAL LIABILITY AGE TO REN7110—
PREMISES Ea pmarenrs $
CLAIMS-MADE ❑OCCUR MEDEXP(Alryoneparscn) 5
PERSONAL&ADV INJURY $
GENERALAGGREGATE b
GEN'LAGGREGATE UM IT APPLIES PER PRODUCTS-COMPIOP AGG 5
POLICY PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE UNIT
Ea acGdenl b
ANY AUTO BODILY INJURY(Porperson) S
ALL OWNED SCHEDULED BODILY INJURY(PoraccldenU 5
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE 5
HIRED AUTOS AUTOS PerarrJdenl
UMSRELIAUAB OCCUR EACH OCCURRENCE $
EXCESS UAS CWIMS.MAOE AGGREGATE $
DELI I I RETENTIONS 5
A WORMERS COMPENSATION WWC3157554 06/0712015 0810712016 X WC srATu OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETOWPARTNER/EXECUOVE YIN E.L EACH ACCIDENT $ 1,000,000
OFFICERAIEMBER EXCLUDED? � NIA
(Mandatory in NH) EL DISEASE-EA EMPLOYO 5 1000000
If as,descritre under
DESCRIPTION OF OPERATIONSbelm EL DISEASE-POLICY UMIT S 1,000,000
MF
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AeaoO ACORD 101,Additional Remarks Bel edule,If Mom space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
RICHARD GARRETT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
DBA: GARRETT CONTRACTING SERVICES ACCORDANCE WITH THE POLICY PROVISIONS.
288 VIA DE AMOR
FALLBROOK, CA 92028 AUTHORREDREPRESENTATIVE
HLR)
01988-2010ACORDCORPOJiATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
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