PMT16-00273 City of Menifee Permit No.: PMT16-00273
29714 HAUN RD. Type: Residential Electrical
'5ACCEL/> MENIFEE,CA 92586
MENIFEE Date Issued: 0 211 012 01 6
PERMIT
Site Address: 32525 BRADLEY RD, MENIFEE,CA Parcel Number: 360-340-002
92584 Construction Cost: $33,600.00
Existing Use: Proposed Use:
Description of INSTALL GARAGE ROOF MOUNTED SOLAR PV SYSTEM 28 MODULES TOTAL, 12 MODULES ON
Work: GARAGE CITY, 16 MODULES MH-HCD, 1 INVERTER 7.84KW
Owner Contractor
JEREMIAH RAXTER PETERSEN-DEAN INC
32525 BRADLEY RD 39300 CIVIC CENTER DRIVE
MENIFEE,CA 92584 FREMONT, CA 94538
Applicant phone:5103716500
JENNY ENCISO License Number.46B117
PETERSEN-DEAN INC
39300 CIVIC CENTER DRIVE
FREMONT, CA 94538
Fee Description f�yt Amount I$1
Solar, Residential or Small Commercial 1 252.00
Building Permit Issuance 1 27.00
Additional Plan Review Electrical 158 157.50
GREEN FEE 1 2.00
SMIP RESIDENTIAL 1 5.00
General Plan Maintenance Fee-Electrical 1 12.60
$466.10
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'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 in
Professions Code a d m license is in full force and a which I must have resided for at least one year prior to completion of
License Class _Lic a No �7 improvements covered by this permit, I cannot legally sell a structure that I have
Expires�Phaia s_ Signature - � built as an owner-building if it has not been constructed in its entirety by licensed
.I-[-- 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 is
submitted or at the following Web site:
❑ 1 hereby affirm under penalty of perjury one of the following declarations: h8o://www.leoinfo.ca.cov/calaw.hlml.
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# By my Signature below, I certify to each of the following: I am the property
❑ 1 have and will maintain workers compensation insurance, as required by ner or authorized to act on the property owner's behalf. I have read this
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 comply
permit is issued.My workers'compensation insurance carrier and policy number are: I applicabl nd county ordina ces and slate laws relating to building
Fnst,m n. thoriz re nta' s of this cityor county to enter the above-
Carder � Inl eu T� —` d for a in 1 cpurposes.
Policy#C.'l t) ON6"! �,lExpires 6 Date
Pr O er or Authorized P�qe F
(This section need not be completed if the permit is for City Business License# `J
one-hundred dollars($100)or less)
HAZARDOUS MATERIAL DECLARATION
certify that in the performance of the work for which this permit is issued,I
I 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 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 a cc ensation provisions of Section 3700 of the Labor amounts specified on the Hazardous Materials Information Guide?
Code,1 0 comp wit ose provision . DYES �NO
Applican, t ; V 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 COVE GE 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 faschooI?
LABOR CODE, INTEREST,AND ATTORNEYS FEES DYES XNO
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 He ktf&S5sVEC`od ,Section 25505 and 25534 concerning
3097 Civil Code) hazar a , aterial re ding.
OWNER BUILDER DECLARATIONS � Datef�
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 O E NER OR AUTH IZED 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 D 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 Contractors 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 licensors 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 penally 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).
❑ 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
Slate of Catfomio \aoossec,�c
Business,Transportation and Housing Agency
CARLOS ARCE 1RTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
wr %v
a�\ J`l rr
Divsion of Codes and Standards
(619) 717-1195 HCD 415 APPLICATION FORMUa
f ❑ Alternate Approval ❑ Technical Services ❑ Inspection To Obtain Insignia
PLEASE CALL FOR INSPECTION City of Menifee SECTION 1-UNIT INFORMATION
$Uli(flng 8s Safety Depl.
I/We are requesting services for the following unit(s): {r
i.LICENSED CONTRACTORS DECLARATION (Ch k Appropriate Box) 2?3 J (ir
i hereby affirm under penalty of perjury that I am Iken��E2��®®tl((jj�o v{��(�f
Chapter 9(commencing with Section 7000)of Division 3 of ihegr6r�s badhrdf�lslbfss Manufactured Home/Moblehome DTN/Permit NO.
Code and my license Is in full force and effect. 1 ClMultifamily Manufactured Home
License Clan.� _Lic.N ' i Exp.Date .hl, } ❑ Commercial Modular(Occupancy Group I f its
❑ Special Purpose Commercial Modular /
Contractor D i- OI(.SCCr2(� l n Decal Num er Date
20WNE - ULD R LAR
Serial Number(s)/VIN Number AA NO.
hereby affirm under penalty of perjury that I am exempt from the Contractors'
License Law for the fallowing reason: Iy'�fF,
fSec.7031.5,Business and Professions Code: Any city or county which requires a permit RT TO
to construct alter.improve,demoflsh,or repair any structure,prior to its issuance,also Manufacturer Name/Model Name 'I /
requires the applicant for such permit to fife a signed statement that he or she a S.' ^ y RT BY
licensed pursuant to the provisions of the Contractors' License Low Chapter 9 i '-f( Yes 1
(commencing with Section 7000 of Division 3 of the Business and Professions Cade)or
that he or she is exempt there from and the basis for the alleged exemption. Any year of Manulocture l(X x
violation of Section 7031.5 by any applicant for a permit subjects me applicant to a Mf
penalty of not more than five hundred dolars($SDO)) ,L —2 q/t J _f'O 22 4L i a 1 7
Insignia/HUD Label Numberpl Y'1 1 ^•�6GL r L / I Tl 1 /
1 1 I, as owner of the property, or my employees with wagges as their sole
compensation.will do the work,and the structure is not intended of offered for sale. SECTION 2-OWNER/APPLICANT INFORMATION] y
15ec. 7044, Business and Professions Code: The Contractors' License Law does not Owner t 1/ Y,G 1
apply to an owner of property, who builds or improves Merean,and who does such
work himself or herself or through his or her own employees provided that such
improvements are not intended or offered fur sale. If, however, the building or Address
improvement is sold within one year of completion, the owner-builder will have the
burden of proving Mothe or she aid not build ortmprove for the purpose of sale.). City Cyo�unty y'� Dp
( 1 I, as owner of the property, am exclusively contracting with licensed Location Atltlress �2�2 J (�'P/ 1/�•
contractors to construct the project T
(Sec.7044,Business and Professions Code.The Contractors'❑sense Low does not apply Park Name(If pplicable) J Park IDH
to on owner of property who builds or improves thereon,and who contracts for such
projects with a conlrac or(s)licensed pursuant to the Contactors'Ucense Low.). Applicant ✓I
( I l am exempt under5ec. B.&P.C.forthu reason: Address I -
City County p
Owner Date Q/\('�� y, �7 Q c� 9 >
3.WORKERS'COMPENSATION DECLARATION Telephone-Applicant i9DC / )22 7J ner i/�-.� L1i_.IG�'T
fir Different Man Applicant)
I hereby offnn under penalty of perjury one of the following declarations:
SECTION 3-CONTRACTPR,ARCHITECT OR EN INEER INFORMATION '
( 1 I have and all maintain a certificate of consent to Labor
tar workers p j
perform lion, as orkf r for by Section N 3700 of the Lobar Code, for the `�
perform of Me work for which ihrs permit IsIssuetl. Contractor's Nartre /'� �1
( I have and will maintain workers'compensation insurance,as required by Address f ( C)�7)�1r ��ry
Section 370D of the Labor Code,for the performance of the work for which Ms permit is �1R (A 1
Issued. My�whorkers`¢m/p�ennsallon insurance carrier and policy number are: Architect/Engineer Name
Carrier 111 l lJr� - I - 15 1 .l- Registration No.
Policy Number ac
- Address
I I I cerify that in the performance of the work,for d wrIch this permit is Issue I
shall not employ any person in any manner so as to become subject to workers' SECTION 4-DESCRIPTION OF WORK/ACTIVITY AND VALUATION
compensa=SECUREWORKMS'
ia.a b'I]DR'a that if I should become subeect to workers'
c'ompensaprovisionse �n 3700 1 the Labor Code,I shal forthwith comply proposed ty- pages 9JnWhWier Describe the ro seo work/aciivi p detail. Attach ere additional
with those structural alterations or additions are proposed. complete plans. specificdetails, a
calculations are required to be attached to this form. Provide the make of an
ApplicantDate)2 1(o appliance to be Installed and provkse complete electrical calculationsctri
oltemo' nsoratlditions.
WARNINGE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, C }
HANDUNDRED
SHALL SUBJECT D EMPLOYER TO CRIMINAL IN PENALTIES AND CIVIL THE
C ST ONE
HUNDRED THOUSAND DOLLARS (IDED FOR S ADDITION TO THE COST OF Tp .t� C NO
COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3704 OF THE LABOR CODE, 1 Iry � '-
INTEREST,AND ATTORNEYS FEES. "' '
4.CONSTRUCTION LENDING AGENCY -i�e W v Sxb J
I hereby affirm under penalty of perjury that there is a construction lending agency Indicate the Total Cost of the Work to be Pedon e Jam( Ll�
for the performance of Me work for which this permit Is Issued (Section 3097, Civil 9
Codes.
SECTIONS-SIGNATURE AND CEATIFICATI
Lenders Name
Lenders Address I/We hereby make appl'�c ter services esignated above.
5.CERTIFICATION
1 Signohxe / DateI certify Mat I have read this application and state that the above informations correct. I agree to campy with all city and county ordinances antl state laws relating "DEPARTMENT USE PNLY-to bulding aonsirucfio by outhortie representatives of this county to enter �/11
upon the above-me ed prape far inspection purposes. Permit Expiration Date // �-CJ❑ APPROVED ❑ CONDITIONS(see reverfeside) / ❑ DISAPPROVE std,�
' Issued By: j�'x.•x"' Date:
. i 7777�
Signs of
Ap cantor Agent Date
Closed/Signature of District Representative Dale
HCD 415.(Rev.07/2013) DISTRIBUTION: YELLOW-DEPARTMENT WHITE-AREA OFFICE PINK-OWNER/APPLICANT
INSTRUCTIONS:
Inspection to Obtain Insignia: Complete Sections 1,2,3,4,5 and Contractor/Owner-Builder Declarations. Submit the application and the required fees to one of
the appropriate Area Office listed below. Upon return receip4 of your processed application(White Copy),contact the designated Area Office to schedule the
inspection date.
Alteration,Addition or Conversion: Complete Sections I.2.3.4.5.and Contractor/Owner-Builder Declarations. Submit the completed application and required
fees to the appropriate Area Office listed below. Upon return receipt of your processed application(White Copy),contact the designated Area Office to schedule
the inspection date.
Technical Services: Complete Sections 1,2.3.and 5. Submit the completed application and required fees to the appropriate Area Office listed below. Upon
return receipt of your processed application(White Copy),contact the designated Area Office to schedule an appointment for services.
Southern Area Office Northern Area Office
3737 Main Street,Suite 400 9342 Tech Center Drive#550
Riverside,CA 92501 Sacramento,CA 95826
(951)782-4420 (9161 255-2501
Alternate Approval: Complete Sections 1,2.3,A.and 5. Submit the completed application and required fees to:Department of Housing and Community
Development.Manufactured Housing Section,P.O.Box 31,Sacramento,CA 95812-0031. If you have any questions you may contact the.
Department at(916)445M38.
SECTION 1 - UNIT INFORMATION: Check one box to indicate the type of unit for which you are requesting services. If Commercial Coach,also
indicate the Occupancy Group Code(i.e.B2,E2,Al,etc.)in the space provided. Enter the unit serial number(s). The serial
numbers)can be located on the Manufacturers Certificate of Origin,the Certificate of Title,registration documents or on the
front cross member of the unit. Enter the year the unit was manufactured. Enter the manufacturers name and/or trade name.
This information can be obtained from the Manufacturers Certificate of Origin,the Certificate of Title,registration documents or
may be designated on the outside of the unit itself. Enter the decal or license number. This number is located on the license plate
issued by DMV or the decal issued by the Department of Housing. Enter the California Insignia Number(s)or HUD Label Numbers)
that were issued for this unit,if known.
SECTION 2- OWNER/APPLICANT INFORMATION: Enter the owners name(s)and address of the unit. If the address for the owner is different
than the location of the unit,provide that information is the"Location Address"area. If the applicant is other than the owner,
enter the name,address and telephone number of the applicant. The Department will contact or correspond with the party that
Is entered as the applicant. If the applicant is the same as the owner,the applicant information is not required to be completed.
SECTION 3- CONTRACTOR,ARCHITECT OR ENGINEER INFORMATION: If the services are being performed by a contractor,enter the
contractors name and address. Also enter the contractors license expiration date. If requested services involve an Architect or
Engineer,enter the architect or engineers name,address and license number.
SECTION 4- DESCRIPTION OF WORK/ACTIVITY AND VALUATION: Provide a description of the work to be performed(i.e.,installing a new roof,
installing new windows,etc.) Enter the total cost of the work to be performed(total contact price).
SECTION 5- SIGNATURE AND CERTIFICATION: The signature of the applicant is required along with the date the form is signed. If the
application is for a replacement insignia or HUD label,the signature must be of the owner of the unit.
CONTRACTOR/OWNER-BUILDER DECLARATIONS
Contractor. Contractors proposing construction are required by state law to provide the following information:
Item I - Licensed Contractor Declaration:Enter the contractors license class,license number,license expiration date and the contractors signature
and date.
-item 3- Workers'Compensation Declaration:Place a check mark next to the declaration regarding the workers'compensation coverage that
L applies to the contractor. If the second declaration is marked,the contractor must also provide the carrier's name and policy number.
This item must be signed by the contractor and dated.
JL -1 m 4- Construction Lending Agency:If there is a construction lending agency for the performance of the work for the service being requested,
enter the name and address of the lending agency. If there is no lending agency involved,enter the word"none".
&nn 5- Certification:The certification must be signed and dated by the contractor or and agent on behalf of the contractor.
1 vener-Builder. If the work or activity as described on the application,is being completed by the owner,the owner must complete the following
items:
,Item 2- Owner-Builder Declaration: Place a check mark next to the declaration which is applicable. If the third declaration is marked,enter the
section number from the Business and Profession Code which provides the exemption and the reason for the exemption. The owner must
also sign and date this section.
Item 5- Certification:The certification must be signed and dated by the owner.
' DEPARTMENT USE ONLY
%* PROVAL OF THIS APPLICATION IS CONDITIONED TO COMPLIANCE WITH REGULA77ONS OF THE DEPARTMENT: Any approval issued by the
partment pursuant to this application is conditioned upon the applicant's compliance with the applicable provisions of the California
M� ministrative Code,Tifie 25,Chapter 3,and the Business and Professions Code as it relates to contracting.
f.,
..4
HCD 415,Side 2(Rev.0712013)
OSP 13131086