PMT15-03472 City of Menifee Permit No.: PMT16-03472
29714 HAUN RD. Type: Commercial Alteration
<A—CCEL/-> MENIFEE,CA 92586
MENIFEE Date Issued: 11/05/2015
PERMIT
Site Address: 28125 BRADLEY RD, Suite#260B, Parcel Number: 337-302-022
MENIFEE,CA 92584 construction Cost: $0.00
Existing Use: Proposed Use:
Description of HOURLY INSPECTION FOR C OF O"CARESITE HEALTH, LLC"
Work:
Owner Contractor
BRADLEY MEDICAL ASSOCIATES
445 SOUTH D STREET
PERRIS,CA 92570
Applicant License Number:
MENIFEE, CA
Fee Description _q Amount I$)
Building Permit Issuance 1 27.00
Inspect-ions not specified 129 129.07
$156.07
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_Pennit_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION ❑ lam exempt from licensure under the Contractors State License Law for th•
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 ii
Professions Code and my license is in full force and effect. which I must have resided for at least one year prior to completion c
License Class License No. improvements covered by this permit, I cannot legally sell a structure that I haw
Expires Signature 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 th,
WORKERS'COMPENSATION DECLARATION Business and Professions Code,is available upon request when this application 1
submitted or at the following Web site:
❑ I hereby affirm under penalty is perjury one the following declarations: hftp://�.leginfo.ca.gov/mlaw.html.
leginfo.ca.gov/mlaw.html.
I have and will maintain a certificate of consentt 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 propert
❑ 1 have and will maintain workers' compensation insurance, as required by owner or authorized to act on the property owner's behalf. I have read thi,
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 compt
permit is Issued.My workers compensation insurance carver and policy number are: with all applicable city and county ordinances and stale laws relating to building
constructigp.I authorize representatives of this city or county to enter the above
Carrier identified a the inspection purposes.
Policy# Expires Date
Property Owner or Authorized Age
(This(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 emolov 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. DYES ❑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 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 outer
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 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 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:
Any city or county that requires a permit to construct, alter, improve, demolish, EPA RENOVATION,REPAIR AND PAINTING IRRPI
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 Iicensure 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).
❑ 1, 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
Arknnwladremnnf
CERTIFICATE • a APPLICATION .— - - - -- -
City of Menifee
Building & Safety Dept.
..Menifee NOV 05 2015
r P4V 331- 3oa- Oaa zceived
DATE t� l j �C_ PERM IT NUMBER �J� c)
BUSINESS NAME TYPE OF BUSINESS
ADDRESS
NAME OF BUSINESS OWNER(S) ---
ADDRESS(IF DIFFERENT FROM ABOVE)
PHONE �S\ EMAIL L.ra\. `sr �or1 ec�c�ec=L�� 2p�
OWNER OF BUILDING
ADDRESS 7 \7 5
PHONE macs k - 551 EMAIL
DESCRIBE EXACT USE OF BUILDING:
Ca ram` "\r�-c-CF, -
PREVIOUS USE OF BUILDING/SUITE c1
APPLICANT ACKNOWLEDGEMENT
Applicant agrees that the Certificate of Occupancy shall be posted in a conspicuous location, and will operate subject
to the City's issuance of the Certificate of Occupancy.
I, _7 11_111ell__k 6� 1_1 s �r_ , hereby agree to comply with the above-described terms in this
Application for Certificate of Occupancy.
DATE Lk S l
APPLICANT
BUS LICENSE DATE ENGINEERING DATE
BUS LIC.NUMBER FIRE DATE
PLANNING DATE EMWD DATE
HEALTH DEPT DATE BUILDING DATE
REMARKS
City of Menifee Building&Safety Department 29714 HOun Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line
CERTIFICATEP• NCY TENANT DISCLOSURE • ' .
��``Menifee
DATE PERMIT NUMBERj- -J
ADDRESS x2e
BUSINESS NAME L.-
INTENDED BUSINESS USE t- e,P - C- .\ S(f-c v s
IS THIS A NEW BUSINESS IN THE CITY OF MENIFEE? ES ��NO� (CIRCLE ONE)
ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? YES (:: L (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? YES NO (CIRCLE ONE)
SQUARE FOOTAGE �pZJ
NUMBER OF EMPLOYEES
NUMBER AND LOCATION OF RESTROOM FACILITIES `4, c 04—
LIST ANY TOXIC CHEMICALS, FLAMMABLE/COMBUSTIBLE LIQUIDS OR GASES USED OR STORED WITH \
MSDS SHEETS AND QUANTITIES OF EACH BELOW OR ON A SEPARATE ATTACHED SHEET(S):
• ARE YOU MAKING ANY IMPROVEMENT TO THE SUITE OR BUILDING OTHER THAN PAINTING,
PAPERING, FLOOR COVERING, MOVABLE CASES,SHELVING OR PARTITIONS NOT ' 9" HIGH?
YES C N (CIRCLE ONE)
• APPLICANT SHALL OBTAIN ALL REQUIRED CLEARANCES AND/OR APPROVALS FROM THE
APPROPRIATE WATER DISTRICT AND FIRE DEPARTMENT PRIOR TO ISSUANCE OF ANY
BUILDING FERMI S
SIGNATURE DATE i� S
PRINT NAME CS
TENANT, R / CONTRACTOR / ARCHITECT / ENGINEER (CIRCLE ONE)
OCCUPANCY GRP TYPE OF CONST STAFF INITIALS
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213