PMT16-00314 City of Menifee Permit No.: PMT16-00314
29714 HAUN RD. T Commercial Alteration
<ACCELA- MENIFEE,CA 92586 yam'
"--- """""" MENIFEE Date Issued:
02105/2016
PERMIT
Site Address: 26960 CHERRY HILLS BLVD,Suite#B, Parcel Number: 337-320-010
MENIFEE,CA 92586 Construction Cost: $0.00
Existing Use: Proposed Use:
Description of HOURLY INSPECTION FOR CERTIFICATE OF OCCUPANCY FOR"TOMAS ARNETA, MD"
Work:
Owner Contractor
VIRGINA C STONE TOMAS ARNETA, MD
P.O. BOX 891027 26960 CHERRY HILLS BLVD STE B
TEMECULA,CA 92589 MENIFEE, CA 92589
Applicant Phone:9517911111
TOMAS ARNETA, MD License Number.. 16-PEOP-00005
TOMAS ARNETA, MD
26960 CHERRY HILLS BLVD STE B
MENIFEE,CA 92589
Phone:9517911111
Fee Description ON Amount lSl
Building Permit Issuance 1 27.00
Inspections not specified 129 129.07
General Plan Maintenance Fee-Building 1 6.45
$162.52
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 forth(
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 it
Professions Code and my license is in full force and effect. which I must have resided for at least one year prior to completion o
License Class License No. improvements covered by this permit, I cannot legally sell a structure that I have
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 the
WORKERS'COMPENSATION DECLARATION Business and Professions Code,is available upon request when this application ie
submitted or at the following Web site:
❑ 1 hereby affirm under penalty of perjury one of the following declarations: http l/www.leainfo.ca aov/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# ❑ By my Signature below, I certify to each of the following: I am the properi
❑ 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 thk
section 3700 of the Labor Code, for the performance of the work for which this application and the information 1 have provided is correct. I agree to complt
permit is issued.My workers'compensation insurance Tamer and policy number are: 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
Carrier idenn'{)E> the irtspec' n purposes.
Policy# Expires /eA, / Date �G
Prop rty Owner 6r Authorized Agent
(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 CNII 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, 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 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 EPRs 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
Acknowledaement.
A
CERJIFICAT OF OCCUPANCY & TENANT DISCLORE APPLICATION "mil
Menifee
j DATE 2 .6
BUSINESS NAME TMO /�-Y(lheia MD
BUSINESS ADDRESS a Mids 151vdfa&
NAME(S) OF BUSINESS�OWNERS
p ` 'I J Ui', (
PHONE NUMBER -t 5 / T ( 1 — 1 f I l EMAIL SC f C( fin, 0k7-7
OWNER OF BUILDING Vl�vr,la , aS (�
OWNER OF BUILDING ADDRESS •01 60 8 9 P 0 9- I rl'I fjm I0. -1 L'.gq
INTENDED BUSINESS USE e N
( IiA 1 11 ,&
IS THIS A NEW BUSINESS IN THE CITY OF MENIFEE? YES NO (CIRCLE ONE)
ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? FJSA lI %m YES NO (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? YES NO (CIRCLE ONE)
SQUARE FOOTAGE E q V 0 NUMBER OF EMPLOYEES
NUMBER AND LOCATION OF RESTROOM FACILITIES I in 1 b 1 ih l I I 1 C
• LIST ANYTOXIC CHEMICALS, FLAMMABLE/COMBUSTIBLE LIQUIDS OR GASES USED OR
STORED WITH MSDS SHEETS AND QUANTITIES OF EACH BELOW OR ON A SEPARATE
ATTACHED SHEET(S):
U_(aV" C1ed#110 S` lies
• ARE YOU MAKING ANY IMPROVEMENTS TO THE SUITE OR BUILDING OTHER THAN PAINTING,
PAPERING, FLOOR COVERING, MOVABLE CASES,SHELVING OR PARTITIONS NOT OVER 5'9"
HIGH?
YES NO (CIRCLE ONE)
Applicant agrees that the Certificate of Occupancy shall be posted in a conspicuous location,and will
operate subject to the Ci ' issuance of the Certificate of Occupancy.
lumIn IS 1 10rhereby agree to comply with the above-
described terms in t is ApplicEgion of Certificate of Occupancy.
SIGNATURE DATE
APN 5?10'C)10 PERMIT NUMBER I 1 1OD
INVOICE AMOUNT ( 70 OCCUPANCY GROUP
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92585 951-672-5777
www.Cityofinenifee.us Inspection Request Line 951-246-6213