PMT15-03167 City of Menifee Permit No.: PMT15-03167
29714 HAUN RD.
'ACCELA,' MENIFEE,CA 92586 Type: Residential Re-Roof
""' MENIFEE Date Issued: 10/13/2015
PERMIT
Site Address: 25791 PELION ST, MENIFEE, CA 92584 Parcel Number: 339-233-003
Construction Cost: $6.000.00
Existing Use: Proposed Use:
Description of INSTALL NEW COOL ROOF SHINGLES OVER EXISTING SINGLE LAYER OF SHINGLES
Work: **CRRC 0890-0009"
Owner Contractor
JEN HAGMAN HOUSETOP ROOFING
25791 PELION STREET 31760 BRIGGS ROAD
MENIFEE, CA 92584 MENIFEE,CA 92584
Applicant Phone:9516798369
RICH CARROLL License Number:371783
HOUSETOP ROOFING
31760 BRIGGS ROAD
MENIFEE, CA 92584
Fee Description ON Amount($1
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_Bldg_Permil_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION ❑ lam exempt from licensure under the Contractors'Slate 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 2nd my license is in full farce and effect. which I must have resided for at least one year prior to completion of
License Class 3 License No. Improvements covered by this permit, I cannot legally sell a structure that I have
Expires 2 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 DEC RATION 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 of the following declarations: httoJ/www.lecinfo.ca.cov/calaw html.
I have and will maintain a certificate of consent of self4nsure 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# trgy my Signature below, I certify to each of the following: I am the property
Or 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
,ram �l construction.I authorize representatives of this city or county to enter the above-
Carrier Sri{/ES w/�// identified property for the iinsppf ctiioon purposes.
Policy# I 2- Expires l2'�/S� i /;s.zl- YT LaL( Date
Property Owner or Authorized Agent
(This section need not be completed if the permit is for City Business License# D 3
one-hundred dollars($100)or less)
I certify that in the performance of the work for which this permit is issued,I HAZARDOUS MATERIAL DECLARATION.
shall not emolov any persons in any manner so as to became 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 WO
Applicant; 6-41 C Date l%3/ram 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 OYES �IQO
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 )r10
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 8.Safety Code,Section 25505 and 25534 concerning
3097 Civil Code) hazardous material reporting.
OWNER BUILDER DECLARATIONS ❑YES NO
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Date
License Law for the reason(s)indicated below by the checkmark(s)I have placed PR06WRTY OWNER OR AUTHORIZED AGENT
next to the applicable Item(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 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 EPKs Renovation Program visit:
❑ ro www.epa.govAead or contact the National Lead Information Center at
I, as owner of the property. or my employees with wages as their sale 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 El 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 contractors)pursuant to the Contractors State License Law). If your project does not comply with EPA RRP rule please fill out the RRP
e
iUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION
DATE 114 PERMIT/PLAN CHECK NUMBER — 31
TYPE: O COMMERCIAL SIDENTIAL 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 ROOF—N>UMBEROF SQUARES
DESCRIPTION OF WORK
�! .4AU — Coe,I! 2.®e
PROJECTADDRESS 1 I�.CJ S
ASSESSOR'S PARCEL NUMBER - LOT TRACT
OWNER NAME - Ap�
ADDRESS f ��/�� �T Building' &fS enifeeiy Depi
PHONE C �S'� �zYD EMAIL -
APPLICANT NAME C
ADDRESS l2 0 l It Receive
PHONE qjZ 9c5 s--»i/ EMAIL
CONTRACTOR'S NAME OWNER BUILDER? O YES/kNO
BUSINESS NAME
ADDRESS (' / S
PHONE 2 4Q.--/ 2 < EMAIL t� /L/AIL•G6"
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION (:f-' 3
VALUATION $ �j,(JOO SO FT 26�o 15� L SO FT
APPLICANT'S SIGNATURE DATE IO
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE (1� PAIDAMOUNT /,
AMOUNT 6 1 O CASH 0 CHECK# O CREDIT CARD VISVMC
PLAN CHECK FEES PAIDAMOUNT 0CASH 0CHECK# OCREDITCARD VISAIMC
OWNER BUILDER VERIFIED OYES 0 NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building&Safety Department 29714 Haun Rd. Menifee, CA 92586 951-671-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
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