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PMT16-00078 City of Menifee Permit No.: PMT 16-00078 29714 HAUN RD. Type: Residential Alteration '�/-�C;CIli MENIFEE, CA 92586 ro.....A Wto-' MENIFEE Date Issued: 0111 212 01 6 PERMIT Site Address: 23571 JOHNSON LN,MENIFEE,CA Parcel Number: 350-112-009 92587 Construction Cost: $10,000.00 Existing use: 1 &2 Family Residence Proposed use: Description of REPLACE DAMAGED DRYWALL&INSULATION 1675 SQ FT SHEET ROCK, 1177 SO FT Work: INSULATION Owner Contractor KEITH LINK 23571 JOHNSON LN MENIFEE,CA 92587 Applicant License Number: KEITH LINK 23571 JOHNSON LN MENIFEE,CA 92587 Phone:9512444943 Fee Description (Qyl Amount($) Building Permit Issuance 1 27.00 Inspections not specified 387 387.21 GREEN FEE 1 1.00 General Plan Maintenance Fee-Building 1 19.36 $434.57 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 carded 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 Professions Code and my license is in full force and effect. which I must have resided for at least one year prior to completion License Class License No. Improvements covered by this permit, I cannot legally sell a structure that I he% 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 tf WORKERS'COMPENSATION DECLARATION Business and Professions Code,is available upon request when this application submitted or at the following Web site: ❑ 1 hereby affirm under penalty of perjury one of the following declarations: htto'//www.lealnfo.ca.gov/calaw.html. 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 3700 of the Labor Code, for the performance of work for which this permit is issued. Property Owner or Authorized Agent Policy# k{By my Signature below, I certify to each of the following: I am the proper ❑ 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 th section 3700 of the Labor Code, for the performance of the work for which this application and the infonnation I have provided is correct. I agree to comp permit is issued.My workers'compensation insurance carrier and policy number are: with all applicable city and county ordinances and state laws relating to buildir construction authorize representa.ves of this city or county to enter the above Carrier identified party for ' spe flon,purposes. Policy# Expires ' %^ Date --F—tig—�-�— PrWertyOwnerorAu rize gent (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 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,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 checklis 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 outs 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(RRP) or repair any structure, pdor 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 EPA's Renovation Program visit: www.epa.go0ead 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). ❑ 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 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 Acknnwlednement_ APPLICATIONBUILDING & SAFETY PERMIT/PLAN CHECK "W Menifee DATE PERMIT/PLAN CHECK NUMBER 10- ODO -75 TYPE: O COMMERCIAL )k RESIDENTIAL 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 O RE-ROOF-NUMBER OF SQUARES DESCRIPTION OF WORK PROJECTADDRESS - ASSESSOR'S PARCEL NUMBER �. LOT TRACT r OWNER NAME ADDRESS PHONE 9��a �yp EMAIL r! APPLICANT NAME r ADDRESS 121F11>1 PHONE 9�� w- EMAIL CONTRACTOR'S NAME OWNER BUILDER? RYES ONO BUSINESS NAME ADDRESS PHONE EMAIL CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION VALUATION$ v SQFT ye7l Dl- LSO FT (� / APPLICANT'S SIGNATURE 7 DATE CITY STAFF USE ONLY DEPARTMENT DISTRIBUTION CNY OF MENIFEE BUSINESS UCENSE NUMBER BUILDING PLANNING ENGINEERING FIRE GREEN F SMIP INVOICE PAID AMOUNT AMOUNT OCASH OCHECK# 0CREDIT CARD VISA/MC PLAN CHECK FEES PAIDAMOUNT 0CASH 0CHECK# OCREDIT CARD VISA/MC OWNER BUILDER VERIFIED 0 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 Keith Link City of Menifee 23571 Johnson Lane Building & Safety Dept. Quail Valley, CA 92587 JAN 12 2016 January 4, 2016 Received City of Menifee 29714 Haun Road Menifee, CA 92586 Dear Building and Safety I, Keith Link give my wife Lenee Link permission to pull a homeowners permit for drywall and installation at my home address 23571 Johnson Lane, Quail Valley CA 92587. Thank You, Keith Link CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of Califpia ) County of On 06 before me, / Date p Here Insert Name and Title of thk6fficer personally appeared �`" Names)of Signers who proved to me on the basis of satisfactory evidence to be the persor)K whose name(s') is/am subscribed to the within instrument and acknowledged to me that he/sheAhey executed the same in his/herAh it authorized capacity(ies), and that by his/herAheir signatur@(s)on the instrument the persort(s), or the entity upon behalf of which the personA acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. DESOMM T.QMNON t WITNESS my hand and official seal. • Fommisstion s 2091229 -: Notary Public-California Z Riverside County L • My Comm.Ez ires Jan 30.2019 Signature Signatu f Notary PLMic Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form t a�ended4ocument. Description of Attached Doc ment - yw Re' .a Title or Type of Document: , Document Date: Number of Pages: / S ner Other han Named Above: Rli�, Capacity(ies) Claipyed by_Signgr(s) Signer's Name: 'r f� Si s Name: ❑Corporate Officer — Title(s): ❑Corpor fficer — Title(s): ❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ ' ed ❑General ❑ Individual ❑Attorney in Fact ❑ Individual ❑ ey in Fact ❑Trustee ❑ Guardian or Conservator ❑Trustee ❑Guardia Conservator ❑ Other: ❑ Other: Signer Is Representing: Signer Is Representing: ©2014 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item #5907 Liz z a x a 6 0 W O Z Z r � � s i1 N d = r- H m o '1I Iz rn o �1 u F� vl o �. F—:'la' � 'IPi 64' , a Z Lo 1-3'4' T BBaCD w N H ° CD (D m 9 Ia+D' Cl S OJ D A !'f C D C N O j 0 � �.a 3 M j p d N O7 C a _ >•� N � y N (lt �^ /�� m 3 O W ", m CD A N (p � n S ro + 0 +r m 1='6'�—� A y O � m _ I X v f C v i H I � a U4 yr a Till I t'il V' I 1 r e r1t o `r as � If � _ O f