PMT16-01239 City of Menifee Permit No.: PMT16-01239
29714 HAUN RD. Type: Commercial Alteration
<ACCELA> MENIFEE, CA 92586
MENIFEE Date Issued: 0412 0/2 01 6
PERMIT
Site Address: 28480 HWY 74, Suite#F, MENIFEE, CA Parcel Number: 329-110-019
92585 Construction Cost: $0.00
Existing Use: Proposed Use:
Description of HOURLY INSPECTION FOR CERTIFICATE OF OCCUPANCY"NAILS TIME"CHANGE OF
Work: OWNERSHIP
Owner Contractor
MOTTE COUNTY PLAZA
4445 S D STREET
PERRIS, CA92570
Applicant License Number.
MENIFEE,CA
Fee Description gtv Amount I51
Building Permit Issuance 1 27.00
Inspections 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 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_Permit_Template.rpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
I hereby affirm under penalty of perjury that I am under provisions of with a licensed contmctor(s)pursuant to the Contractors State License Law).
Chapter9(commencing with section 7000)of Division 3 of the Business and ❑I am exempt from licensure under the Contractor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
License Class License No. By my signature below 1 acknowledge that,except for my personal residence
Expires Signature in which I must have resided for at least one year prior to completion of
WORKER'S COMPENSATION DECLARATION improvements covered by this permit.I cannot legally sell a structure that I
have built as an owner-builder if it has not been constructed in Its entirety by
❑I hereby affirm under penalty of perjury one of the following declarations:I licensed contractors.I understand that a copy of the applicable law,Section
have and will maintain a certificate of consent of self-insure for worker's 7044 of the Business and Professions Code,is available upon request when
compensation,issued by the Director of Industrial Relations as provided for this application is submitted or at the following website:
by Section 3700 of the labor Code,for the performance of work for which sysy,,y leainfo.ca.aov/calaw.html.
this permit is issued.
Policy N Date
❑I have and will maintain worker's compensation insurance,as required by PROPERTY OWNER OR AUTHORIZED AGENT
section 3700 of the Labor Code,for the performance of the work for which ❑By my signature below I certify to each of the fallowing:I am the property
this permit is issued.My worker's compensation insurance carrier and policy owner or authorized to act on the property owner's behalf.I have read this
number are: application and the information i have provided is correct.I agree to comply
Carrier with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy N Expires enter the above identified rp'roperty for inspection purposes.
(This section need not to be completed is the permit is for one-hundred Ct�U W-k/ � Date }
dollars($100)or less PROPERTY OWNER OR AUTHORIZED AGENT
❑I 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 CITY BUSINESS LICENSE p
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the workers compensation provisions of section 3700 of the Labor
Code,I shall forthwith comply with those provisions. Will the applicant or future building occupant handle hazardous material or a
Applicant Date mixture containing a hazardous material equal to or greaterthat the
amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes ❑No
UNLAWFUL,AND SHALL SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES Will the intended use of the building by the applicant or future building
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN occupant require a permit for the construction or modification from South
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR Coast Air Quality Management District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguidelines
CONSTRUCTION LENDING AGENCY ❑Yes ❑No
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 1000 feet of the
lending agency for the performance of the work which this permit is issued outer boundary of a school?
(Section 3097 Civil Cade) ❑Yes ❑No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm under penalty of perjury that I am exempt from the permitting checklist.I understand my requirements under the State of
Contractors License Law for the reason(s)indicated below by the California Health&Safety Code,Section 25505 and 25534 concerning
hazardous material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 ayes ❑No
Business and Professions Code).Any city or county that requires a permit to Date
construct,alter,improve,demolish or repair any structure,prior to its PROPERTY OWN ER OR AUTHORIZED AGENT
issuance,also requires the applicant for the permit to file a signed statement -
that he or she is licensed pursuant to the provisions of the Contractors State EPA RENOVATION,REPAIR AND PAINTING(RRP)
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the The EPA Renovation,Repair and Painting(RRP)Rule requires contractors
Business and Professions Code)or that he or she is exempt from licensure receiving compensation for most work that disturbs paint in a pre-1978
and the basis for the alleged exemption.Any violation of Section 7031.5 by residence or childcare facility to be RRP-certified firms and comply with
an Applicant for a permit subjects the applicant to a civil penalty of not more required practices.This includes rental property owners and property
than($500). managers who do the paint-disturbing work themselves orthrough their
❑I,as owner of the property,or my employee with wages as their sole employees.For more information about EPA's Renovation Program visit:
compensation,will do( )all of or( )portion of the work,and the structure is www.epa.gov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-800424-LEAD(5323).
Code,The Contractors State License Law does not apply to an owner of a ❑An EPA Lead-Safe Certified Renovator will be responsible for this project
property who,through employees'or personal effort,builds or improves the
property provided that the improvements are not intended or offered for Certified Firm Name:
sale.If,however,the building or improvement is sold within one year of Firm Certification No.:
completion,the Owner-Builder will have the burden of proving that it was
not built or improved for the purpose of sale. ❑No EPA Lead-Safe Certified Firm is required for this project because:
❑I,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractors State License Law does not apply to an owner of a If your project does not comply with EPA RRP rule please fill out the RRP
Acknowledgement.
[CrICATE OF PA � • � . . y �.
City of Menifee
Building & Safety Dept.
Menifee APR 2 0 2016
DATE IQ011Lq
BUSINESS NAME `- ceived
BUSINESS ADDRESS Q S-6-&6-
NAME(S) OF BUSINESS OWNERS 1 !t
PHONE NUMBER ( (- rj6O — (Jj, I EMAIL -wm
OWNER OF BUILDING
OWNER OF BUILDING ADDRESS
INTENDED BUSINESS USE ave(A
IS THIS A NEW BUSINESS IN THE CITY OF MENIFEE? YES to
(CIRCLE ONE)
ARE YOU THE FIRST TENANT TO OCCUPY TH IS SPACE? YES (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? YES 10 (CIRCLE ONE)
SQUARE FOOTAGE NUMBER OF EMPLOYEES
NUMBER AND LOCATION OF RESTROOM FACILITIES
• 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 SHEETS):
• 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 ocation,and will
operate subject to the City' issuance of the Certificate of Occupancy.
I, ( (N. C� D0 alN hereby agree to comply with the above-
described terms in this Application of Certificate of 0 upancy.
SIGNATURE i D WA41 DATE
CITYSTAFF USE ONLY
APN - PERMIT NUMBER 01
INVOICE AMOUNT IQLe •V I OCCUPANCY GROUPfb
City of Menifee Building&Sofety Department 29714 Houn Rd. Menifee, CA 92536 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
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