PMT16-01718 City of Menifee Permit No.: PMT16-01718
29714 HAUN RD.
'tJICCE-A? MENIFEE, CA 92586 Type: Residential Alteration
MENIFEE Date Issued: 06/03/2016
PERMIT
Site Address: 28290 LOOKOUT POINT LN, MENIFEE, Parcel Number: 333-401-019
CA 92586 Construction Cost: $5,688.00
Existing Use: 1 &2 Family Residence Proposed Use:
Description of INSTALL 15'x 10 LATTICE AND 15'x 17.5'SOLID ALUMAWOOD PATIO COVER WITH 1 GFI OUTLET,
Work: 1 FAN,6 POST LIGHTS
Owner Contractor
JEFFREY NIELSEN TRADER DAN'S INC
28290 LOOKOUT POINT LANE 840 S ROCHESTER AVE STE C
MENIFEE,CA 92585 ONTARIO, CA 91761
Applicant Phone:9093900555
DONALD DAUGHENBAUGH License Number:517575
TRADER DAN'S INC DBA ROOMS N'COVERS
840 S ROCHESTER AVE STE C
ONTARIO, CA 91761
Fee Description Qtv Amount i$1
Receptacle, Switch,Outlet&Fixture B 151.00
Building Permit Issuance 1 27.00
Deck/Patio, non-standard 1 133.00
GREEN FEE 1 1.00
SMIP RESIDENTIAL 1 1.00
General Plan Maintenance Fee-Building 1 6.65
General Plan Maintenance Fee-Electrical 1 7.55
$327.20
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 slated,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_Permil 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 contractor(s)pursuant to the Contractors State License Law).
Chapter9(commencing with section 7000)of Division 3 of the Business and o I am exempt from licensure under the Contractors State License Law for
Professions Code and my license is in full force and effect. L the following reason:
License Clalsss i ; L( n o. J By my signature below I acknowledge that,except for my personal residence
Expires"Cl1 Imo!/" Signature — in which I must have resided for at least one year priorto completion of
�lFr-- improvements covered by this permit.I cannot legallysell a structure that
WORKER'S COMPENSATION DECLARATION have built as an owner-builder if it has not been constructed in its entirety by
D 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 Professians 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.m.goy/calaw.htmi.
this permit is issued.
Policy# Date
rave 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 o 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
"� with all applicable city and county ordinances and state laws relating to
Carrier building construction.I authorize representatives of this city or county to
Policy#id`A'57tl007,S,G-)1-" Expires enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred Date
dollars($S00)or less ' PROPERTY OWNER OR AUTHORIZED AGENT
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#
workers compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the workers corn ensation provisions of Section 3700 of the Labor
Cade,I shall-fora th c ply th those provisions. 77 Will the applicant or future building occupant handle hazardous material or a
Applicant Date 7 �j mixture containing a hazardous material equalto or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO 16R WORKER'S COMPENSATION COVERAGE IS o 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($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 Oyes ONO
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) Oyu ❑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
California Health al Safety Code,Section 25505 and 25534 concerning
Contractors License Law for the reason(s)indicated below by the
hazardous material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5
oyes o No
Business and Professions Code).Any city or county that requires a permit to Date
construct,alter,improve,demolish or repair any structure,priorto 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 Contactors State EPA RENOVATION,REPAIR AND PAINTING IRRPI
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the The EPA Renovation,Repair and Painting(RRP)Rule requires contactors
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
D 1,as owner of the property,or my employee with wages as their sale 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.eov/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 a D 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. D 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
C A• • r: .
Menifee
DATE PERMIT/PLAN CHECK NUMBER Q 1
TYPE: O COMMERCIAL RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O�ADDITION CALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
9-kEW OPLUMBING ORE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK
PROJECT ADDRESS
ASSESSOR'S PARCEL NUMBER y�-,A$5� 3-(6j0\-Q,q LOT TRACT
OWNER NAME
J(4'_� �U�I�J"�17 Building & Safety D pt.
ADDRESS L 0/1� LO/OkO "- !' J JUN 0 3 201
PHONE 7 6� 5�� ''�� l �7/ '\ EMAIL Receiveb
APPLICANT NAME 1J4 to °� a 11�Iit c71
ADDRESS / _Z
PHONE -/fJ I / �'� ��5-�— EMAIL
CONTRACTOR'S NAME 0IM-9 .A/ I Ir[/1cS OWNER BUILDER? O YES
BUSINESS NAME C�
ADDRESS gqO S. Otvt 4l0 CR' �7116
PHONE Q0� "�R'O��" EMAIL
CONTRACTOR'S STATE
/LIC NUMBER 75-77 LICENSE CLASSIFICATION
VALUATION$ �b �o S G� �' L SQ FT > /
APPLICANT'S SIGNATURE DATE
CITYSTAFFUSEONLY
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN ' SMIP T1-'
INVOICE ^ �1� PAIDAMOUNT
AMOUNT 1. 0�7 1'QO O CASH O CHECK q O CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT C CASH O CHECK n C CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED DYES C NO DLNUMBER 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
LEDGER � TRACK
OWNER �41� I VLQ'Vi �r� f�i LNJPECTION REQUIRED
ADDRESS �CL�j � p+
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ROOMS N' COVERS PROPOSED ADDITIONS) I Z , `� "M 0 3 201,
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