PMT15-03204 City of Menifee Permit No.: PMT15-03204
29714 HAUN RD. Type: Residential Re-Roof
�A -L/�. MENIFEE,CA 92586
MENIFEE Date Issued: 1 0/1 512 01 5
PERMIT
Site Address: 27610 GROSS POINTE DR, MENIFEE, Parcel Number: 335-253-001
CA 92586 Construction Cost: $6,000.00
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING SHINGLES, INSTALL NEW COOL ROOF SHINGLES
Work: "CRRC#0890-0009`*
Owner Contractor
ROLAND RIOLIX AL'S ROOFING
27610 GROSS POINTE DRIVE 20690 OLD ELSINORE ROAD
MENIFEE,CA 92586 PERRIS,CA 92570
Applicant Phone:9512295783
AL GRAY License Number: 716337
AL'S ROOFING
20690 OLD ELSINORE ROAD
PERRIS, CA 92570
Fee Description OYtr 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_Permit_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION ❑ lam exempt from licensure under the Contractors'Stale License Law forth
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 i
Professions Code and my license is in full force and effect. which I must have resided for at least one year prior to completion t
License Class C— License No. 7/ 6 73 7 improvements covered by this permit,I cannot legally sell a structure that I hay
Expires j I Signature G built as an owner-building if it has not been constructed in its entirety by license
contractors. I understand that a copy of the applicable law, Section 7044 of if
WORKERS'COMPENSATION DECLARAT ON Business and Professions Code,is available upon request when this application
submitted or at the following Web site:
MVrhereby affirm under penalty of perjury one of the following declarations: http!/v^�^� lepinfo ca aov/calawhtml.
I have and will maintain a certificate of consent of self-insure for workers'
compensation,issued by the Director of Industrial Relations as provided for by Date
Section 370D of the Labor Code,for the performance of work for which this Property Owner or Authorized Agent
permit is issued.
Policy# Q 10 :2 r c! O j � ❑ By my Signature below, 1 certify to each of the following: 1 am the proper
owner or authorized to act on the property owners behalf. I have read tf
have and will maintain workers' compensation insurance, as required issus application and the information I have provided is correct. I agree to comr
section of the Labor Code, for the performance with all applicable city and county ordinances and state laws relating to buildii
permit is issued.My workers'compensation insurance carder
the work for which this er and policy number are: construction.I authorize representatives of this city or county to enter the abov
Carrier S ct identified property for the inspection purposes.
� j )� Dale
Policy# s� P(,_,$'D y ^/S Expires Property Owner or Authorized Agent
(This section need not be completed if the permit is for City Business License#
one-hundred dollars($100)or less)
HAZARDOUS MATERIAL DECLARATION
❑ I 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
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,1 shall forthwith comply with those provisions. `0 / (5, DYES ❑NO
Applicant; !'��� Date; / I WIII 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 checkii
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL for guidelines
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND DYES ❑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 out
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE boundary of a school?
LABOR CODE, INTEREST,AND ATTORNEYS FEES DYES ❑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 Califomia Health&Safety Code,Section 25505 and 25534 concerning
3097 Civil Code) hazardous material reporting.
DYES ❑NO
OWNER BUILDER DECLARATIONS Date
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the reason(s)indicated below by the checkmark(s)I have placed PROPERTY OWNER OR AUTHORIZED AGENT
next to the applicable item(s)(Section 7031.5.Business and Professions Code: EPA RENOVATION REPAIR AND PAINTING(RRP)
Any city or county that requires a permit to construct, alter, improve,demolish,
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 contractor
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) a Division 3 the Business and Professions Code) a 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 require
d practices.This includes rental property owners and property
re
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 proje-
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 If our project does not comply with EPA RRP rule please fill out the RRP
licensed contractor(s)pursuant to the Contractors State License Law). Y P j
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION
j Menifee
DATE /r /S /S PERMIT/PLAN CHECK NUMBER
TYPE: ❑COMMERCIAL RESIDENTIAL ❑MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA []SIGN
SUBTYPE: ❑ADDITION []ALTERATION ❑DEMOLITION ❑ELECTRICAL ❑MECHANICAL
❑NEW ❑PLUMBING ErRE-ROOF-NUMBER OF SQUARES ZS-XP
DESCRIPTION OF WORK G �r- lee /<( c)a
PROJECTADDRESS p ra 2n,� T-
HE a
ASSESSOR'S PARCEL NUMBER LOT TRACT Building & Safety Dept.
PROPERTY OWNER'S NAME �q� �r a✓ r OCT 15 20 5
ADDRESS rJ o rcr r, kReGei d
PHONE SS/- 67 C 2 71 EMAIL ld
APPLICANT NAME
ADDRESS zoL 9. old t471,jn-re R IO Pe I I-;f Cr( PC ?a
PHONE $I/— ?Z£ - T7 e 3 EMAIL CONTRACTOR'S NAME r u G/'r y X OWNER BUILDER? [:]YESZNO
BUSINESS NAME l� ` ad i'iv,
ADDRESS Zod o 01,1 9 2 J-7 v
PHONE Y'r/— ee5,- S P 3 EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION C
VALUATION$ 7�60a SOFT ZS LSQFT
APPLICANT'S SIGNATURE J2-- DATE �H /� i5`
s
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAIDAMOUNT
AMOUNT •-IO .�� OCASH OCHECK# 0CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT 0CASH 0CHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-5777
www.cityofinenifee.us Inspection Request Line 951-245-6213
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