PMT16-02350 City of Menifee Permit No.: PMT16-02360
_ 29714 HAUN RD. Type: Residential Demolifion
<-►CCEL/-> MEN IEEE, CA92586
MENIFEE Date Issued: 07/21/2016
E R M � T
Site Address: 25870 TRUMBLE RD, MENIFEE, CA Parcel Number: 329-240-013
92585 Construction Cost: $3,500.00
Existing Use: Proposed Use:
Description of DEMO EXISTING MOBILE HOME, 1848 SF
Work:
Owner Contractor
PATRICIA GROB
25870 TRUMBLE ROAD
MENIFEE,CA 92585
Applicant License Number:
MENIFEE,CA
Fee Description C1yt Amount ISl
.�suance 1 27 00
Demolition Permit 1 140.00
GREEN FEE 1 1.00
$168.00
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 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_BIdg Pernit Template.rpt Page i 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 D 1 am exempt from licensure 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 l 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
Dlhereby affirm under penalty of perjury one of the fallowing deciarations:l 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 Cade,is available upon request when
compensation,issued by the Director of Industrial Relations as provided for this applicatior S submitted or at the following website:
by Section 3700 of the Labor Code,for the performance of work for which
this permit is issued. www.le in v a w.html.
Policy q Date
P NOW ER❑I have and will maintain workers compensation insurance,as required by 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 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 con ruction.I authorize representatives of this city or ounty to
Policy# Expires enterthe v defied property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred �d
dollars($100)or less
Date
P 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 11
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 or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes D 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($100,000),IN occupant require a permit for the construction or modification from South
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR Coast Air Quality Management the
t(SCtionor odi permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES fo Coast
Airlines
Qua
CONSTRUCTION LENDING AGENCY o Yes o No
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 1000 feet of the
lending agency for the performance of the work which this permit is Issued outer boundary of a school?
(Section 3097 Civil Code) D Yes o No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm under penalty of perjury that I am exempt from the permitting checklist.I understand my requirements under the State of
Contractors License Law for the reason(s)indicated below by the California Health&Safety Code,Section 25505 and 25534 concerning
checkmark(s)I have placed next to the applicable item hazardous material reporting.$)(Section 7031.5 oyes D 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 IRRPI
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 apre-1978
and the basis for the allegedexemption.Aicany nt loci of Section of not o residence or childcare facility to be RRP-certified firms and comply with
than
Applicant fora permit subjects the applicant toacivil 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 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 1-800424-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. o No EPA Lead-Safe Certified Firm is required for this project because:
D 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.
L
NOwl",
71►C ._iS�feAUJjIViIAW I1IMil[ti: 1al:�_,UUI11FAire]0j
'' Menifee
DATE PERMIT/PLAN CHECK NUMBER
TYPE: O COMMERCIAL O RESIDENTIAL C MULTI-FAMILY O MOBILE HOME 0 POOL/SPA 0 SIGN
SUBTYPE: O ADDITION O ALTERATION "W' 6EMOLITION O ELECTRICAL O MECHA&IICAL
Ity of Menifee
O NEW O PLUMBING O RE-ROOF-NUMBEROFSQUARES Buildin & S
DESCRIPTION OF WORK
PROJECTADDRESS SS O -r?.UM/t 15LI5 eri1&P R
ASSESSOR'S PARCEL NUMBER LOT TRACT
OWNER NAME 'r Q
ADDRESS
PHONE 95/- 7�- 6)�76 EMAIL
APPLICANT NAME R4 ru rJ ,5i4N r'
ADDRESS , 0 So - 7 C✓wa ✓1A//i C A4 9.;ZS
PHONE 95I — 5DO— 5'7Z 6 EMAIL
CONTRACTOR'S NAME OWNER BUILDER? ES O NO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ _ Q FT L SO FT
APPLICANT'S SIGNATURE DATE l
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP 1<
INVOICE PAID AMOUNT �,
AMOUNT OCASH OCHECK# CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT I 0CASH 0CHECK# O CREDIT CARD 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
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City q Menifee
Building S
AP IMa"Dept.
JUL 21 2016
-------- Received
A'CMoW:LE"DGMENT
'notary:Ru.bIIc'or:other•be pasting this cerilflcate verifies only .the identify:of'the IndfvlduaJ
who signed fha•document to which this certificate Is
attached, and not the truthfulness,.accuracy, or
valldlt of:
document
Slate'of California
County of C-Z e
On—(� lL-0/& before me, •Y4e4 '
'e n ' o /
/ �O ✓'arc (j`G(Insert name and title of the off cer)Personally appeared �G` �O�
who proved to me on the basis of satisfactory evidence to be the perscn(s) whose name(s)Is/are
psubscribed to the within Instrument and acknowledged to me that he/she/they executed the same in
erso (s), oatheeriz-edntIty °apse (aes),et�d•Ehat y#4sfher/t#lelrslgnefure(s}or�•t+le•�nstr menldhe
person(s), or t'he,ehtlly upon behalf of which the Person(s) acted, executed the Instrument.
I certify under PENALTY OF PERJURY under the laws of the
Paragraph Is true and correct, State of California that the foregoing
WITNESS my hand acid offfclalseal,
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city of Menifee
Building & Safety Dept.
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JUL 21 20%
Received
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CITY OF MENIFEE �.
BUILDING AND SAFETY DEPAW ENT
PLAN APPROVAL
REVIEWED BY O
DATE
*Approval of these plans shall not be construed to be a rmit for,or an
approval of,any•iolation of any provisions of the federal state or city
regulations and ordinances, This set of approved plans ust be kept on the
jobsite until completion. V
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