PMT15-03835 City of Menifee Permit No.: PMT15-03835
29714 HAUN RD.
�CCELA1? MENIFEE, CA 92586 Type: Residential Re-Roof
MENIFEE Date Issued: 1211412015
PERMIT
Site Address: 27200 PALOMA WAY, MENIFEE, CA Parcel Number: 336-011-016
92586 Construction Cost: $6,500.00
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING LAYERS, INSTALL NEW COOL ROOF SHINGLES
Work: **CRRC#0890-0009*'
Owner Contractor
CARRIE JACKSON INLAND VALLEY ROOFING
27200 PALOMA WAY 2235 KERN STREET
MENIFEE,CA 92586 SAN BERNARDINO, CA 92407
Applicant Phone:9098873469
ALYSHA MARMOLEJO License Number:981684
INLAND VALLEY ROOFING
2235 KERN STREET
SAN BERNARDINO,CA92407
Fee Description Oyrt 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_B1dg Permit_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION ❑ 1 am 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 lr
Professions Cod a,�d y license is in full force and efJe�t:;, /^y which I must have resided for at least one year prior to completion o
License Class e7 Lice �X/'(�O improvements covered by this permit, I cannot legally sell a structure that I have
Expire Signature '9 built as an owner-building If It has not been constructed in its entirety by licensec
contractors. I understand that a copy of the applicable law, Section 7044 of the
WORKERS'COMPENSATION DECLARATION Business and Professions Code,is available upon request when this application ie
submitted or at the following Web site:
cif hereby affirm under penalty of perjury one of the following declarations: hftpl/www.leciinfo.ca.gov/calaw.htm(.
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 3700 of the Labor Code, for the performance of work for which this
permit is issued. u Property Owner orAuthorized Agent
Policy# q� f ,2 d Jcr 0 ❑ By my Signature below, I certify to each of the following: I am the propery
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 thie
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 complt
permit is issued.My workers'comp nation insurance cartier and policy number are: with all applicable city and county ordinances and state laws relating to buildinE
construction.I authorize representatives of this city or county to enter the above
Cartier ,, I U1, identified property for the inspection purposes.
Date
Policy# 6'1 Ab Expires [O CP
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
❑ 1 certify that in the performance of the work for which this permit is issued,I
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?
Cade,I sha hwith comply with those provisions. DYES ❑NO
Appliwn; �- Date;42 V y 16— 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.1 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: EPA RENOVATION.REPAIR AND PAINTING RRP1
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 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 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 Finn 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 7D44, 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
Acknowledgement.
SAFETYBUILDING & PERMIT/PLAN CHECK APPLICATION
�d�enifee
DATE ( — _ 15 PERMIT/PLAN CHECK NUMBER
TYPE: ❑COMMERCIAL RESIDENTIAL []MULTI-FAMILY ❑MOBILE HOME POOL/SPA []SIGN
SUBTYPE: []ADDITION ❑ALTERATION ❑DEMOLITION ❑ELECTRICAL.❑MECHANICAL
❑NEW ❑PLUMBING ®RE-ROOF-NUMBER OF SQUARES 42
DESCRIPTION��O..{{F,. WORK tQ- 7 „ C Od j
PROJECTADDRESS 2--7poo W CL r
ASSESSOR'S PARCEL NUMBER 'a�03U•C)%%�O�U LOT 11) TRACT
PROPERTY OWNER'S NAME O� AIZZIIFp UrAC Y;
ADDRESS d
PHONE EMAIL
"I rty of
APPLICANTNAME 6 Building 8 Safety Dept.
ADDRESS 1j pEC 14 2015
PHONE EMAIL
CONTRACTOR'S NAME ,i u I OWN RBUILDER? YES 0
BUSINESS NAME ^ V
ADDRESS 222S t• 7
PHONE 0I6q EMAIL ft ( (]"!
CONTRACTOR'S STATE UC NUMBER 2�J 10 S Y LICENSE CLASFICATION C
VALUATION$ 1a,500 SQFT Ql-X LSQFT
APPLICANT'S SIGNATUR 141/ ' E� DATE
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAID AMOUNT
AMOUNT OCASH OCHECKN OCREDITCARD NSA/MC
PLAN CHECK FEES PAIDAMOUNT OCASH 0 CHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building&Safety Deportment 29714 Houn Rd.Menifee,CA 92586 951-572-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
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