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PMT16-01463 City of Menifee Permit No.: PMT16-01463 '29714 HAUN RD. Type: Residential Addition 4;XCCEU/ MENIFEE, CA 92586 MENIFEE Date Issued: 05/11/2016 PERMIT Site Address: 30851 LAJOE ST, MENIFEE, CA 92584 Parcel Number: 360-461-002 Construction Cost: $300.00 Existing Use: 1 &2 Family Residence Proposed Use: Description of ADD 42' U/G GAS LINE FOR FUTURE BBQ&FIREPIT, PORTION UNDER PATIO COVER TO BE Work: SLEEVED Owner Contractor JEFFERY BURROUGHS 30851 LAJOE STREET MENIFEE, CA 92584 Applicant License Number: JEFFERY BURROUGHS 30851 LAJOE STREET MENIFEE, CA 92584 Phone: 9519703218 Fee Description Oft Amount(S) Plumbing Fixtures and Vents,fixtures 1 116.00 Building Permit Issuance 1 27.00 GREEN FEE 1 1.00 General Plan Maintenance Fee-Plumbing 1 5.80 $149.80 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 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. A.A_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 1 hereby affirm under penalty of perjury that I am under provisions of with a licensed contractor(s)pursuant to the Contractors State License Law). Chapter!)(commencing with section 7000)of Division 3 of the Business and ❑I am exempt from Iicensure under the Contractors 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 I acknowledge that,except for my personal residence 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 ❑1 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,forthe performance of work for which www,leginfo.ca.gov/calaw.htmi.permit is issued. Policy# Date PROPERTY OWNER OR AUTHORIZED AGENT ❑I have and will maintain workers compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which ❑By my signature below I 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: 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# Expires enter the above ident led property for inspection purposes. (This section need not to be completed is the permit is for one-hundred Date 15-((-No dollars($100)or less ROPERTY NER OR AUTHORIZED AGENT D 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$1 workers 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 orgreaterthat the amounts specified on the Hazardous Materials Information Guide.' WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes ❑No 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($300,000),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)7 See permitting checklist IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidelines 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 Code) o 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 underthe State of Contractors License Law for the reason(s)indicated below by the California Health al Safety Code,Section 25505 and 25534 concerning hazardous material reporting. checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 oyes ❑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 OWNER 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 or through their ❑1,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.aov/lead or contact the National Lead Information Center at not intended or offered for sale.(Section 7044,Business and Professions 1-800-424-LEAD(5323). Code;The Contractors State License Law does not apply to an owner of ❑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 thatthe 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: ❑1,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. BUILDING , ♦ SAFETY PERMIT/PLAN APPLICATION '�yMenifee DATE 5'I01 tO PERMIT/PLAN CHECK NUMBER lQ' L1 TYPE: []COMMERCIAL ORESIDENTIAL MULTI-FAMILY []MOBILE HOME POOL/SPA ❑SIGN SUBTYPE: ❑ADDITION ❑ALTERATION []DEMOLITION []ELECTRICAL []MECHANICAL ❑NEW MPLUMBING []RE -ROOF-NUMBEROFSQUARES DESCRIPTION OF WORK k vie pLy Ire t / zza 1 1c9n law ov�e6 PROJECT ADDRESS 3095f Ue S} ' ' C f11 tCX gaSD I City of Menifee ASSESSOR'S PARCEL NUMBER 3(p(��L-��p� — ��,� LOT TRACT eY PROPERTY OWNER'S NAME �Q MAY 1 ADDRESS 30 9S L,L) of mQ ol t•CJt, Rerpivedl PHONE g -3d EMAIL �kefL�I ��^11e(I L'AT ✓�� APPLICANT NAME ADDRESS PHONE EMAIL CONTRACTOR'S NAME OWNER BUILDER? YES❑NO BUSINESS NAME ADDRESS PHONE EMAIL CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION VALUATION$ 7300— SO FT L SQ FT APPLICANT'S SIGNATURE DATE DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER BUILDING PLANNING ENGINEERING FIRE GREEN SMIP INVOICE PAID AMOUNT AMOUNT '� ,Ljq O.CASH OCHECK# OCREOITCARD VLSA/MC PLAN CHECK FEES PAID AMOUNT O CASH O CHECK# O CREDITCARD VISA/MC OWNER BUILDER VERIFIED OYES 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 951-246-5213 Jeffrey John Burroughs 30851 LaJoe St Menifee, City of Menifee CA 92584 30ding & Safety Dept. May 10"2016 MAY 11 2016 To : City of Menifee Received For : Permit for Gasline in Back Yard I Jeff Burroughs am giving Jessica Marie Lebrescu permission to pull permits for gas line in backyard for Barbeque Grill and a Fire Pit, at my residence in Menifee CA 92584, 30851 LAJOE STREET Thank you Jeffrey John Burroughs TI�I h kCjG7/2� t o 951-970-3218 " Off' /�() � (0 t to e,,,.n e v'f California Acknowledgment Form 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 validityof dlat document State of California County of R l ye rsi a r SS. On ) ciy I6 2016 - - before me, A-r-y s. ��Inl<F, , No-6rX Cv6)tr �-2 ��Ye there insert name and hue of the otfi personally appeared y Sohn (3urroughs — — — —who proved to me on the basis of satisfactory evidence to be the persorl(s)whose names)is/are-subscribed to the within instrument and acknowledged to me that he/sWtbey executed the same in his/herllWr au- thorized capacity(ies), and that by his/heF/t[i&signature(a)on the instrument the perso*), or the entity upon behalf of which the person(sj 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. Seal WITNESS my hand and official seal. - . OFFICIAL SEAL ARTI S.PARIKH 9 Signature of Notary NOTARY PUBLIC•CALIFORNIAU s' COMM.NO.2019174 RIVERSIDE COUNTY MY COMM.EXP.APRIL 12.2017 Optional Information To help prevent fraud,it is recommended that you provide information about the attached document below. tt*This is not required under California State notary public law."'* Document Title:S-1-Ai6 e--P+ 'r"/ 61-ts l the Pc tw 1 E #of Pages: Notes i