PMT15-03262 City of Menifee Permit No.: PMT15-03262
29714 HAUN RD.
![ - CCELA— MENIFEE, CA 92586 Type: Residential Electrical
MENIFEE Date Issued: 10/2112015
PERMIT
Site Address: 28064 OAK HAVEN LN, MENIFEE, CA Parcel Number: 340-320-060
92586 Construction Cost $1,500.00
Existing Use: Proposed Use:
Description of ADD 7 UNDER CABINET LIGHTS, 1 CAN LIGHT,&1 DEDICATED CIRCUIT FOR MICRO
Work:
Owner Contractor
GARY POTTER A A A RESTORATION INC
28064 OAK HAVEN LN 29850 2ND STREET
LAKE ELSINORE, CA 92532-2420
Applicant Phone:9514715828
KIRK MUNIO License Number: 834839
A A A RESTORATION INC
298502ND STREET
LAKE ELSINORE,CA
Fee Description City, Amount
Receptacle, Switch,Outlet&Fixture 9 156.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Electrical 1 7.80
$191.80
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_Permd_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION
I hereby affirm under penalty or perjury that I am licensed under provisions of ❑ I, as owner of the property an exclusively contracting with licensed
Chapter 9(commencing with section 7000)of Division 3 of the Business and contractors to construct the project(Section 7044, Business and Professions
Professions Code and my license is in full f c d effect.
License Class G License No. 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
Expires Signature licensed contractor(s)pursuant to the Contractors State License Law).
WORKERS'COMPENSATION DECLARATION
❑ I am exempt from Iicensure under the Contractors'State License Law for the
❑ 1 hereby affirm under penalty of perjury one of the following declarations: following reason:
I have and will maintain a certificate of consent of self-Insure for workers'
compensation,issued by the Director of Industrial Relations as pmvided for by By my signature below I acknowledge that, except for my personal residence in
Section 3700 of the Labor Code, for the performance of work for which this which 1 must have resided for at least one year prior to completion of
permit is issued. improvements covered by this permit, I cannot legally sell a structure that I have
Policy# 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
❑ 1 have and will maintain workers' compensation insurance, as required by Business and Professions Code,is available upon request when this application is
section 3700 of the Labor Cade, for the performance of the work for which this submitted or at the following Web site:hfto,//www.leginfo.m,gov/calaw-html.
permit is issued.My workers'compensation insurance carrier and policy number are:
Carier_gwM ,'(J9✓!: roperty Weer orAuthorize Agent Date
Expires_ 3y-/Gz policy# Cg%SOo y'Of/Z
Name of Agent Kff j Phone#$°ct�YZ-!550 ❑ By my Signature below, I certify to each of the following: I am the property
owner or authorized to act on the property owner's behalf. I have read this
(This section need not be completed if the permit is for application and the information I have provided is correct. I agree to comply
one-hundred dollars(5100)or less) 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-
0 I In d pro
that t certifyy the performance the work for which this permit Is issued,I identified r the inspection purposes.
shall not that any persons any
manner so as to become subject to the l�/J
workers'compensation laws of California, and agree that If I should become
subject to the workers'compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. r Property Owner or Authorized Agent Date
-
Date; Applicant; City�' City Business License# O
�C/ a
WARNING: FAILURE TO SECURE WORKERS' `
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL HAZARDOUS MATERIAL DECLARATION
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS WILL THE APPLICANT OR FUTURE BUILDING
($100,000), IN ADDITION TO THE COST OF COMPENSATION, AYES OCCUPANT HANDLE A HAZARDOUS MATERIAL ORA
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE MIXTURE CONTAINING A HAZARDOUS MATERIAL LABOR CODE, INTEREST,AND ATTORNEYS FEES pNO EQUAL TO OR GREATER THAN -THE AMOUNTS
CONSTRUCTION LENDING AGENCY 1 SPECIFIED ON THE HAZARDOUS MATERIALS
I hereby affirm that under the penalty of perjury there is a construction lending INFORMATION GUIDE?
agency for the performance of the work which this permit Is issued (Section
3097 Civil Code) WILL THE INTENDED USE OF THE BUILDING BY THE
APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE
Lender's Name ❑YES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION
Lender's Address NO FROM THE SOUTH COAST AIR QUALITY MANAGEMENT
DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
OWNER BUILDER DECLARATIONS GUIDE LINES
I hereby affirm under penalty of perjury that I am exempt from the Contractor's PRINT NAME:
License Law for the reason(s)indicated below by the checkmark(s)I have placed ❑YES WILL THE PROPOSED BUILDING OR MODIFIED FACILITY
next to the applicable item(s)(Section 7031.5. Business and Professions Code: BE WITHIN 1000 FEET OF THE OUTER BOUNDARY OF A
Any city or county that requires a permit to construct, alter, Improve, demolish, qNO SCHOOL?
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
provisions of the Contractor's State License Law(Chapter 9 (commencing with I HAVE READ THE HAZARDOUS MATERIAL
Section 7000)of Division 3 of the Business and Professions Code)or that he or ❑YES INFORMATION GUIDE AND THE SCAQMD PERMITTING
she is exempt from licensure and the basis for the alleged exemption. Any CHECKLIST. I UNDERSTAND MY REQUIREMENTS
violation of Section 7031.5 by any Applicant for a permit subjects the applicant to pNO UNDER THE STATE OF CALIFORNIA HEALTH AND SAFETY
a civil penalty of not more than($500).) 11 CODE, SECTION 25505, 25533 AND 25534 CONCERNING
❑ I, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIAL REPORTING.
compensation,will do ( )all of or( )porting of the work, and the structure is PROPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code; ,/
The Contractor's State License Law does not apply 46 an owner of a property X (%
who, through employees' or personal effort, builds or improves the property,
Provided that the improvements are not intended or offered for sale.If,however,
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
wrpose of sale).
APPLICATIONBUILDING & SAFETY PERMIT/PLAN CHECK
t
Menifee
DATE -Z ,IS PERMIT/PLAN CHECK NUMBER $^QSZ
TYPE: ❑COMMERCIAL ❑RESIDENTIAL ❑MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA [-]SIGN
SUBTYPE: ❑ADDITION ❑ALTERATION ❑DEMOLITION [-]ELECTRICAL ❑MECHANICAL
❑NEW ❑PLUMBING [-I RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK 7 P D/ e50 C•,hc-vT
Ave IvIlre o.
Zv
PROJECTADDRESS plyK Yg1�iJ LIV• ptEj•// C
ASSESSOR'S PARCEL NUMBER q40 - $2Q-Q(at() LOT TRACT ZS 27(42
PROPERTY OWN ER'SNAME
Z$r,
ADDRESS y�
PHONE EMAIL
APPLICANT NAMEC�
ADDRESS FgW0 lay
PHONE 96('5Tq--i7TLq EMAIL
CONTRACTOR'S NAME k'jrl< MS4,n, OWNERBUILDER? ❑YES❑NO
BUSINESS NAME 'A-4*
ADDRESS 101 9W Zf+�
PHONE � lr-'9 / ,�// EMAIL
CONTRACTOR'S STATE LIC NUMBER .S�iy l� LICENSE CLASSIFICATION
VALUATION$ 1500 FT L SQ FT
APPLICANT'S SIGNATURE ADATE /OOTYSTAFFUSEONLY
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
B (DIN PLANNING ENGINEERING FIRE GREEN SMIP a 3-7 (o 3 q
INVOICE PAID AMOUNT
AMOUNT Iqk S`° OCASH *CHECKB I&ILlIkk 0CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT �P (Lt O CASH O CHECK# O CREDITCARD VISA/MC
OWNER BUILDER VERIFIED O YES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building& Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
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_ BUILDING AND SAFETY DEPARTMENT ,
�C PON APPRO",AL� A&
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REVIEWED E'l
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—� 'Approval of these plans shall not be construed to be a permit for,or an Q)
approi al of,any vio�d� t p any prov�si 3aftA state or city
regul ions anddrdirrt�eMis set of approv d plag ust be kept on V ��
! ��ti until comptotiomf, cis
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