PMT16-01360 City of Menifee Permit No.: PMT16-01360
29714 HAUN RD. Type: Residential Electrical
<ACCEL/-> MENIFEE, CA 92686
MENIFEE Date Issued: 04/2912016
PERMIT
Site Address: 30114 SANTA ROSALIA DR, MENIFEE, Parcel Number: 360-013-004
CA 92584 Construction Cost: $1,000.00
Existing Use: Proposed Use:
Description of EXTERIOR ELECTRICAL REPAIRS, REWIRE 5 LIGHTS&GFI FIXTURES
Work:
Owner Contractor
VIRGINIA ALVARADO PREBOT CONSTRUCTION
30114 SANTA ROSALIA DR 365 W SAN JACINTO AVENUE
MENIFEE, CA 92584 PERRIS, CA 92570
Applicant Phone:9514534437
PRIMITIVO PREBOT License Number:427208
PREBOT CONSTRUCTION
365 W SAN JACINTO AVENUE
PERRIS,CA 92570
Fee Description ON Amount($1
Receptacle, Switch,Outlet&Fixture 5 136.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Electrical 1 6.80
$170.80
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 Cade 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_Tempiate.rpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
I herebyaffirm under penalty of perjury that I am under provisions of with a licensed contractors)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 Contractors State License Law for
Professions Code and my license is in full force and effect. Q thefollowing reason:
License Class � Licens o. O By my signature below I acknowledge that,except for my personal residence
S 3� (p
Expires Signature in which I must have resided for at least one year prior to completion of
improvements covered by this.permit.I cannot legally sell a structure that I
WORKER'S COMPENSATION DECLARATION 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 workers 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 www.leginfo.ca.aov/caIaw.htmL permit is issued.
Policy# Date
have and will maintain workers 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 1 certify to each of the following:I am the property
this permit is issued.My workers compensation insurance carrier and policy owner or authorized to act on the property owners behalf.I have read this
number are: I I application and the information I have provided is correct.I agree to comply
ws
Carrier with all applicable city and county ordinances and state la relating to
p ` building construction.I authorize representatives of this city orcountyto
Polity#I \� S�1 Expires enter the above identified property for inspection purposes.
(This section need notto be completed is the permit is for one-hundred 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 became subject to the CITY BUSINESS LICENSE#
workers compensation laws of Califomia,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the work s compensation provisions of Section 3700 of the Labor
Code,I shall fo comply w'h th proylsions. Will the applicant or future building occupant handle hazardous material or a
`�Applicant I Date mixture containinga hazardous material equal to or greater that the
amounts s - ified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes X0
UNLAWFUL,AND SHALL SUBJECT AN 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 for guidelines
CONSTRUCTION LENDING AGENCY ❑Yes.40
1 herebyaffirm 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 bou dary of a school?
(Section 3097 Civil Code) ❑Yes
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 Califomia Health&Safety Code,Section 25505 and 25534 concerning
hazarco terial reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 Dues o
Business and Professions Code).Any city or county that requires a permit to Date_�fz fiG
construct,alter,improve,demolish or repair any structure,prior to its p RTY OWNER OR AU O IZED AGENT TT""-�
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 or through 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.eoa.eov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-80D-424-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 ..TT
not built or Improved for the purpose of sale. uAllo EPA Lead-Safe Certified Finn 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.
SAFETYBUILDING & PERMIT/PLAN CHECK APPLICATION
Menifee
DATE (W( PERMIT/PLAN CHECK NUMBER ` I1(J D 3
TYPE: O COMMERCIAL PESIDENTIAL O MULTI-FAMILY OUIDBILEHOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION QLECTRICAL O MECHANICAL
O NEW O PLUMBING O RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK `1 `t
PROJECTADDRESS /� /�
ASSESSOR'S PARCEL NUMBER 3100- p13-Cbq LOT TRACT
OWNER NAME
ADDRESS ` (Dive
PHONE (aQ Y� 22qpb EMAIL N
APPLICANTNAME
/21/ r / !(//d
ADDRESS („tJ S pU ( 1L !~ r cZS 7e)
PHONE 9/95/ q-53 -4f 1(3 3 EMAIL
CONTRACTOR'S NAME /�/�� OWNER BUILDER? O YES O NO
BUSINESS NAME 6A- 'fJ ox
ADDRESS 3Ae, U) S ! D
PHONE 26/ !fsj�� L/ �� EMAIL
CONTRACTOR'S STATE LIC NUMBER �Z 3'Z 6 q LICENSE CLASSIFICATION
VALUATION$ Oc? SOFT /0 L SQ FT
APPLICANT'S SIGNATURE DATE Z /
.DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE I GREEN 1 SMIP
INVOICE PAID AMOUNT AMOUNT O' 0CASH 0 O CHECK# OCREDITCARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT I OCASH OCHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED O 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
State of California °SING s
FOR INSPECTION PLEASE CALL Bsuiness,Tronsportoljpnagd using Agency ra� '�G
JESSE RUIZ PARTMENTOFHOUSINGANDCJMM NITY DEVELOPMENT s
Division of Codes and Standards City of Menifee 3� at
951-212-2575 HCD 415 APPLICATIO�WNE�R9 & Safety Dept, `
❑ Alternate Approval r ❑ Technical-Services Inspection To Obtain Insignia -
CONTRACTOR/OWNER-BUILDER DECLARATIONS- SECTION 1-UNIT INF RMATION -
Notrequked For Special Purpose CommerclalModular
I.LICENSED CONTRACTORS DECLARATION I/We are request[g services far toe follow in unB(s): D-i I I
(check Appropriake es e i ve d I p'�•
I hereby mmmn under penalty of perjury that am licensed under provisions of fo e/
Chapter 9(commending with Section 7000)of Division 3 of Business andProtessian's- U�Manufactured Aome/Moblehome DTN/Permit N0
Code antl my license is in full force and effect. O Mulfifamly Manufactured Home
7 - , O Commercial Modular(Occupancy Group- I
Ifcense Class !: Uc.No.`/ / Date."�l .i / Fee
El Special Purpose Commercial Modular ��YJ 7
Contractor T Y/M l�'1 I ✓ f� �� �)v Oate.y �.L �T--! L /J .
Decal Number /� r 7 .. BIe
2.DWNER-BUILDER DECLARATION "
999��erwI Number(s),/VIN Num AA NO.
I hereby affirm undeng molly of perjury that I am exempt from the Contractors' �� ^ - r
Uconse Law for the s and
reason: I i (? / _7
(Sec.7031.5,Budness and improve.demolis Code: Any ny or c which requiresissua oe, aNf RT TO
re construct appDantforsuch
peen ft repair any structure,dscat prior to its issuance,also Manufacturer Name/Model Name
requires the pursuant
for such provisions
i to Ilea siggner) ' License
that he a she i9 - FIT BY
licensed omme pursuant Se the 7000 of Division
of the Co a Business
License Low Chapter 9 Jr,
(commencing will,Section t 7e00 from
Div nit th basis Business.and edProfessionsexemption. or t
that he or she is exempt(here hom icatl the hoes For the alleged exemption. Any
viola/ion o/otmomtha 5by any red donfmorapennif subject the opplfconffoacivil
Year of Manufacture r
penalty of not more than five hundred dollars(5500JJ
Insignia/-HUD Label Number(sliL/i
[ ) 1, as owner of the property. or my employees with wages as their sale
compensation,will do the work and the structure not intended of offered for sale. SECTION I-OWNER/APPUCANT INFORMATION
(Sec 7044, Business and Professions Cade: The Contractors' License Law does not t Owner ��,: : ?/rL/t� / .�r r`.
apply to an owner of property, who builds or Improves thereon,and who does such r7/ : -
work himself or herself or Una h his or her own employee; provided that such .^ - -
improvements are not intended or offered for sole. If, however, the building or Address)Cuc.7`F) 11: r
Improvement is said within one year of completion, the owner-builder call have the / / �� i - r
burden of proving that he or she ciidnof build orimprove for the purpose of sale.). Cily1 t h 9 6"—( 1 )ir)'Cdd 1A l i r.✓'"i i%c/ Lp/=
[ 1 I, as owner of the property, am exclusively contracting with licensed
contractors to construct the protect Location Address
ISec.70".Business and Professions Code:The Conhaclou'Ucense Low does not apply Park Nome(if Appdcable) Parklf3R
to an owner of property who owlds or improves thereon,and who contracts for such
projects with a cantracfor(s)licensed pursuant to the Contractors'License Low.). Applicant/ 1•- �� �� /��-94
[ 1'l am exemplander Sec- B.B P.C.for thb moron: Address
County Tip
Owner bete City
3.WORKERS'COMPENSATION DECLARATION Telephone-Appticont-���/-L/ � I- L/C)Homeowner
pf DiflerenritoJan
I hereby affirm under penalty.of perjury one of the following declarations:
SECTION 3-CONTRACTOR,AREHRECf OR ENGINEERJNFORMATION
(V) I_have and wil maintain a certificate of consent to selftinsure for workers' �' J '�
compervicyon, as provided for by Section 3700 of the Labor Code, for the Contractor's NameLLG'i%
performance of the work for which this pennl ensued -
I have and will maintain workers compensation insurance, as required by Add ( �)! THr,Section 3700 of the Labor Cotle.For the performance of the work for which this permt Ts
Issued. My workers'compensation innssurance carrier antl policy numberare: Architect/Engineer NamCarrier C'r/I-)-/{ %�C/f/^ lL�`/�l 0- Registration No
Policy Number Address
[ I I certify that in the performance of the work for which this permit is issued I
shot[ not employ any person In any manner so as to become subject to workers' SECTION 4-DESCRIPTION OF WORK/ACTIVITY AND VALUATION
compensation laws of Caltorna,and agree that R 1 should became subject to workers'
compensation provisions of Section 370D of the Labor Cotle,I shall forthwith comply Describe the proposed work./activity in detail. Attach additional pages d necwith thase-prowsions. structural alterations or additions are proposed complete plans, specifications,(' �n /.��/ wlculalbns are required}o be atach@d fo this icon. Provide the make and Applicant /' `?!//. 1"1 J L4 ' V-1 JT Dote / appliance to be Installed antl provide complete electrical calculations (or
alternations or additions.
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,
AND.SHALL'SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS f$100.ODD). IN ADDITION' TO THE COST OF
COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE *rt :f v ei •f�)Y/ I fir/ / I. 1
INTEREST,AND ATrORNEY'S FEES.
4.CONSTRUCTION LENDING AGENCY l(VC Ilfi.0 SDI t..' IR I..?, I L
I hereby otfrm under penalty of peduiy that there is a construction lending agency
for the performance of the work for which this permit 6 Issued (Section 3097, Crud Indicate the Total Cost of the Work to be Performed
Code).
SECTION 5-SIGNATURE AND CERTIFICATION
Lendefs Nome
Lendefs Address I/We hereby make ap [cation for he se ry ces desl Died above.
5.CERTIFICATION
Sgnafure__01%i �� Date
I certify that I-have read this appfication.ond state that the above information 4
correct. I ogree7o comply with all city and county ordinances and slate laws relating ' "DEPARTMENT USE ONLY" '
to building construction,and hereby authorize representatives of this county to enter �O
upon the above-mentioned property for inspection purposes. Permit Expiration Dale h
D APPROVED O C ITIONS(see reverses e) O DISAPPROVED(see reverse side)
Issued By. �i�jrNX .�/dJ®/7.!/"-- lC Dale:
(gnatureof AppficmYor Agent p Dale
- Closed If Signature of District Representative Dote
HCD 415(Rev.07/2013) _ - DISTIBUTION: YELLOW-DEPARTMENT WHITE-AREA OFFICE PINK-OWNER/APPUCANT
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All construction shall comply with the ail
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X-1 the 2012 IBC, 2012 UMC, 2012 UPC
and the 2011 NEC. a
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