PMT16-01625 City of Menifee Permit No.: PMT16-01625
29714 HAUN RD.
'5ACCIEL/-> MENIFEE, CA 92586 Type: Pool/Spa -Residential
MENIFEE Date Issued:
05/24/2016
PERMIT
Site Address: 26268 ADELINA DR, MENIFEE, CA 92584 Parcel Number: 360-600-008
Construction Cost: $25,000.00
Existing Use: Proposed Use:
Description of INSTALL POOL WITH 2 LIGHTS
Work:
Owner Contractor
ALTIE&TRACEY HOLCOMB INFINIUM CONSTRUCTION
26268 ADELINA DR 42801 LARRY LEE LANE
TEMECULA, CA 92592
Applicant Phone:9517979476
KORY ROBERTS License Number.976676
INFINIUM CONSTRUCTION
42801 LARRY LEE LANE
TEMECULA,CA 92592
Fee Description OOt r Amount I51
Swimming Pool/In-Ground Spa 1 467.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
SMIP RESIDENTIAL 1 4.00
General Plan Maintenance Fee-Mechanical 1 0.00
$499.00
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 staled,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_Sldg_Permft_Templatexpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
with a licensed contractor(s)pursuantto the Contractors State License Law).
I hereby affirm under penalty of perjury that 1 am under provisions of
Chapter9(commencing with section 7000)of Division 3 of the Business and D I am exempt from licensure under the Contractor's State License Law for
Professions Code and my license is in full force and effect. ,I the following reason:
License Class License Io. / ��s{' By my signature below I acknowledge that,except for my personal residence
Expires ignature 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 COM ENSATION 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 worker's 7044 of the Business and Professions Code,is available upon requestwhen
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 ,,y,,y,�,Ieainfo.ca.Rov/calaw.html.
this permit is issued.
Policy# Date
wrbave 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 following: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 f e with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# �xpires Z 20 enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred Date
dollars($100)or less PROPERTY OWNER OR AUTHORIZED AGENT
,WT`c.rtify 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#
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the wri ker's compensation provisions of Section 3700 of the Labor
Code,1 shall f 1 ith t ly with those provisions. Will the applicant or future building occupant handle hazardous material or
Applica Date 2 mixture containing a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes No
UN LAWFUL,AND SHALL SUBIECf AN EMPLOYER TO CRIMINAL PENALTIES 14
Will the intended use of the building by the applicant or future building
AND OVIL 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 a 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 bo dary of a school?
(Section 3097 Civil Code) ❑Yes o
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 co cerning
FyTz o aterial r orting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 frj¢ o
Business and Professions Code).Any city or county that requires a permit to Date r
construct,alter,improve,demolish or repair any structure,prior to its PROPEON 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 Contractor's 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 Iicensure 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.epa.gov/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 Contractor's 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 Contractor's 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.
City of Menifee
Building & Safety Dept.
APPLICATION& SAFETY PERMIT/PLAN CHECK BUILDING
�El
Received
Menifee
DATE PERMIT/PLAN CHECK NUMBER �m 1�Q r d1 2-1—
TYPE: O COMMERCIAL . RESIDENTIAL C MULTI-FAMILY O MOBILE HOME POOL/SPA 0 SIGN
SUBTYPE: 0 ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
NEW O PLUMBING O RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK
PROJECTADDRESS
ASSESSOR'S PARCEL NUMBER '>IQO lQQ(7 —008bT TRACT
OWNER NAME
ADDRESS ^ Z�ppl,, I I1 4 & � g
OA
PHONE I,IQ,O- Mg- to "-
` - EMAIL
APPLICANT NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S NAME OWNER BUILDER? O YES ^NO
BUSINESS NAME InQlAc
• 'a
ADDRESS 4sigQ
PHONE 44�;l 2�L• D 13-1 EMAIL \ % . WX")Il
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
J�
VALUATION$ 00 gySO FT L SO FT
APPLICANT'S SIGNATURE III `/ DATE cS 17,
DEPARTMENT DISTRIBUTION 1` CRY OF FEE BUST SLICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GRIEEN SgIP
INVOICE q pAID.AMOUNT
AMOUNT { • OCASH 0CHECK# OCREDITCARD VISA/MC
PLAN CHECK FEES PAID AMOUNT OCASH OCHECK# OCREDIT CARD VISA/MC
OWNER BUILDER VERIFIED O YES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building& Safety Deportment 29714 Houn Rd. Menifee, CA 92586 951-572-6777
www.cityo finenifee.us Inspection Request Line 951-246-6213
INFINIUM 42801 Larry Lee Lane
Temecula CA 92592
95 9476-offcmeCONSd i� bTM www.infiniumpoofs.co City CA License#976676
Building of Menifee Classification C-53 Et
9 & Safety Dept.
MAY 2 4 2016
To whom it may concern:
I, Kory Roberts, give Karen McRoberts permission to obtain building permits and city licenses
for Infinium Construction for the calendar year of 2016. If you have any questions please
contact my personal cell phone at 951-428-7717 or the office at 951-797-9476.
Thank you,
Kory Roberts, Owner
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