PMT16-02428 City of Menifee Permit No.: PMT16-02428
29714 HAUN RD. Type: Commercial Demolition
�ACCELA> MENIFEE, CA92586
-1111"`k-- MENIFEE Date Issued: 0 712 812 01 6
PERMIT
Site Address: 27851 ENCANTO DR, MENIFEE, CA Parcel Number: 333-040-002
92586 Construction Cost: $11,000.00
Existing Use: Proposed Use:
Description of DEMO EXISTING 5,000 SF BUILDING
Work:
Owner Contractor
JIM WHOLT H F G PACIFIC EXCAVATION INC
20450 VIA BURGOS 28690 CAPANO BAY COURT
YORBA LINDA,CA 92887 MENIFEE,CA 92584
Applicant Phone:9092393574
HARRY GRAUN License Number:902479
H F G PACIFIC EXCAVATION INC DBA PACIFIC DEMOLITIO
28690 CAPANO BAY COURT
MENIFEE, CA 92584
Fee Description ON Amount IS)
Building Permit Issuance 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_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
I hereby affirm 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 o I am exempt from licensure under the Contractors State License Law for
Professions Code and my license is in full force and effect. �j the following reason:
License Class C'� / U. se l0./G�-�/ 7 g m signature below I acknowledge that,except for m
99 Y Y g g p my personal residence
ExptrePX 31 —j' Signature in which I 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
o 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,for the performance of work for which
this permit Is issued. www.leeinfo.ca.Rov/calaw.html.
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 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.1 have read this
number are: application and the information I have provided is correct.I agree to comply
Carrier 5 / /�- / f'✓n-C/ with all applicable city and county ordinances and state laws relating to
.� building construction.I authorize representatives of this city or county to
Policy#G 6�2 [:7 5 y 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($100)or less
PROPERTY OWNER OR AUTHORIZED AGENT
o I certify that in the performance of the work for which this permit is issued,
I shall not emolov 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 compensation provisions of Section 3700 of the Labor
Code,I sha11 f hv oh comply with those provisions. �r { Will the applicant or future building occupant handle hazardous material or
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 LS o Ye `SrNa
UNLAWFUL,AND SHALLSUBJECTAN EMPLOYER TO CRIMINAL PENALTIES Will the Intended use of the building by the applicant or future building
AND CIVIL FINES UPTO 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)7 See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguidellnes
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 boon ary of school?
(Section 3097 Civil Code) o 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 California Health&Safety Code,Section 25505 and 25534 concerning
ha rdous ma erial reporting.
checkmark(s)I have placed next to the applicable Rem(s)(Section 7031.5 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 pant in a pre-1978
and the casts for the alleged exemption.Any violation of Section 7031.5 by residence or childcare facility to he RRP-certified firms and comply with
than
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
o 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.Rov/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 ❑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:
o 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 RAP rule please fill out the RRP
Acknowledgement.
APPLICATION& SAFETY PERMIT/PLAN CHECK BUILDING
Menifee
DATE PERMIT/PLAN CHECK NUMBER - Q
TYPE: 'COMMERCIAL O RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SP O. IGN
SUBTYPE: O ADDITION O ALTERATION DEMOLITION O ELECTRICAL Dept.
O NEW O PLUMBING O RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK (• ` ni
If Received
PROJECT ADDRESS 1,eti:'T2c� CA S— 6
ASSESSOR'S PARCEL NUMBER ?jnj7j-[x{O-�f,� LOT TRACT
OWNER NAME
ADDRESS ' (J^' i A V ✓� 0 S \ o�J6. `�Vl C
ny .5
PHONE / � �r�ay D- EMAIL r
APPLICANT NAME
ADDRESS�
PHONE 9�Q EMAIL ct •- : i c- I� e-1 o
CONTRACTOR'S NAME OWNER BUILDER? O YES O
BUSINESS NAME n h -(r.
ADDRESS D (r d C R a.v d 9 G+ C ) - �1Yr'
PHONE C?�i 9 rJ S�/ �5 �� EMAIL G L: c/v.v " ex,- ' ^A (, ev
CONTRACTOR'S STATE LIC NUMBER LOp'� y�7 LICENSE
/ CLASSIFICATION C 1
VALUATION$ J C, C SO FT 0 0 L SQ FT �r
APPLICANT'S SIGNATURE,,, - DATE ^ -_Q
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP k
INVOICE
AMOUNT PAID AMOUNT [j CASH O[HECK#. OCREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT OCASH OCHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED Q YES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building& Safety Department 29714 HOUn Rd. Menifee, CA 92556 951-672-6777
www.cityofinenifee.Us Inspection Request Line 951-246-6213
p -
j
City of Menifee
M �N , T-�-� � � � ' f Building & Safety Dept.
JUL 2 8 2016 >-
IL
Received O
I U
LL
CITY OF ME IFEE LL
n� BUILDING D SAF DEPARTMENT O
D PLAN APPR VAL
u� REVIEWEDIBY li
DATE
`Approval of these plans shall not b construed to be a permit for,or an
i approval of,any vi lation of any pr visions of the federal,state or city
regulations and or inances. This s t of approved plans must be kept on the
jobsite until completion.
(J -e
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South Coast Air Quality Management District LISPS-Mail Form and Fee To: All Others-Mail Form and Fee To:
21865 Copley Drive, Diamond Bar,CA 91765-4182 SCAQMD Bank of America Lockbox Services
Phone:(909)396-2336 (vvww.agmd.gov) Lockbox#55641
PO Box 55641 2706 Media Center Drive
,g Rule 1403 Form Notification of Los Angeles,CA 90074-5641
e B Los Angeles,CA 90065
Demolition or Asbestos Removal F
I Fax these type of Notification Forms to(909)396-3342 and mail the originals within 48 hrs C'
DEMOLITION DEMOLITION ASBESTOS REMOVAL PLANNED RENO I PROCEDURE 4 PLAN 1 PROCEDURE 5PLAN project EMERGENCY ORDERED C
Project Type J (Fre ining) (R tion) (Mnuap Urgency
NotificationType ORIGINAL I CANCELLATIONI REVISION AMOUNT I REVISION DATES I REVISION OTHER Building & Safety Dept. ® u
o ❑ ❑ ❑ ❑
Contractor Information:Notifications should be submitted by the contractor performing the project JUL 2 8 2016
CSLBLI=se 902479 Cal.OSHA REG AOMDID 157083 CHECK P960 FEE 16P. S3 DATE 07/19/2016 rRaEcru 1 LL
Company Name HFG Pacific Excavation,Inc.dba Pacific Demolition Ust Site Supervisor(s) C
Address 28690 Capano Bay Ct. Harry Graun (909)239-3574 -
City Menifee Slate CA Zip 92584
Completed by Deanna Graun Phone (951)672-2357
Site Information: Copies of this notification and the CAC asbestos survey report must be kept at the worksite during this project
Site Name 27851 Encanto Dr., Menifee, CA 92586
SiteAddress 27851 Encanto Dr., Menifee,CA 92586 CmssSheet McCall
See City Menifee Slate CA Zip 92586 County Riverside
See Owner John Wholt Contact John Wholt Phone (714)264-8253
OMnerAddress 20450 Via Burgos City Yorba Linda State CA Zip 928B7
Desaibework Demolish Building
DesrnbeWorkLocationIs) 27851 Encanto Dr.,Menifee,CA 92586
Demolition Project Start Date 08102/2016 Demolition Project End Date 08108/2016 PrgadWakShR Day 0 Swing () Night O
'BUILDING SIZE in sq ft 5000.00 Number of Floss 1 Building Age(Yeas) 45 Number of Buildings or Dwelling Units 1
Building Pdorl SCHOOL HOSPITAL CONDO/APT PUBUCBLDG. INDUSTRIAL COMMERCIAL OFFICE UNVCCLLEGE HOUSE SHIP OTHER
Present Use ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ❑
Required Building Information ASBESTOS SURVEY? ASBESTOS FOUND? ASBESTOS REMOVED? BUILDING TO BE DEMOLISHED?
YES (E) NO 0 YES Q NO () YES 0 NO() YES 0 NO 0
Asbestos Information: Do not provide this information in demolition notifications,see pg 2
Asbestos Amount to be Removed FRIABLE CLASS I CLASS II ATOTALUM
MOUM 0.00
in sq ft
AmountofEach ACOUSTICCEILING LINOLEUM INSULATION FIREPROOFING DUCTING STUCCO MASTIC FLOOR TILES(VAT)
Type ofAsbestos
insgft DRYWALL PLASTER TRANSITE ROOFING OTHER PLEASE DESCRIBE OTHER TYPE OF ASBESTOS:
Asbestos Removal From SURFACES ❑ PIPES ❑ COMPONENTS ❑
Asbestos Detection Procedures:Check the procedures and analytical methods used to determine the presence of asbestos in the building.See SurveyCheddist
SURVEY ❑ BULK SAMPLING ❑ INSPECTION ❑ CAG ASSUMED AS ASBESTOS-PACM ❑ PLM ❑ PCM ❑ TEM ❑
Controls:Check the combination of Rule 1403 procedures used to control asbestos emissions.(Procedure 4 and 5 submit plans for AQMD prior approval)
PROCEDURE NUMBER 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
Emergency Asbestos Removal:Check the sudden unexpected event and attach a letter from the person affected by the emergency explaining how this event
caused unsafe conditions,equipment damage or unreasonable financial burden. For disturbed/damaged asbestos materials see Pmoodure5 Guidelines.
FIRE FLOOD WATER DAMAGE EARTHQUAKE NUISANCE VANDALISM HEALTH/SAFETY FINANCIAL BURDEN EQUIPMENT DAMAGE OTHER
El 11 El El El El El El El
Name of Person Declaring/ Date of Hourof
Authorizing the Emergency Plane Emergency Emergency
_AQMD'USE:ONLY: SGt2EEtJED'BY RECENED, POSTMARKED EN'JEREp:BY NOTIFICATION# - -
2 Fees are per Notification and vary according to the 2TOTAL AMOUNTof asbestos removed or the demolition 2BUILDING SIZE
South Coast Air Quality Management DiSnid,Notification of Demolition or Asbestos Removal Fan(2016,06) Page 1 of 2
South Coast Air Quality Management District USPS-Mall Form and Fee To: All Others-Mail Form and Fee To:
21865 Copley Drive,Diamond Bar,CA 91765-4182 Bank of America Lockbox Services
Phone:(909)396-2336 (www.agmd.gov) SCAQMD Lockbox#55641
PO Box 55641 2706 Media Center Drive
Rule 1403 Form Notification of Los Angeles,CA 90074-5641 Los Angeles,CA 90065
p 1 ° Demolition or Asbestos Removal
Demolition Information:All asbestos containing materials must be removed priorto any demolition activity
Asbestos Removal Company Name
5M Contracting Inc. Date of Asbestos Removal 0 7/1 812 0 1 6
Check work practices to prevent,suppress and contain dust,and dust controls to be use at the demolition site
SPRAY WATER EXIT GRATES TARP TRUCKSIBINS FENCE SCREENS STONE TRUCK PADS TIRE WASHING SOIL STABILIZERS OTHER
o ❑ o ❑ ❑ ❑ ❑
Contingency Demolition Plan:Check actions to be followed if unexpected asbestos is found during demolition or asbestos material becomes disturbed,crum-
bled,pulverized or reduced to powder.DislurbedlDamaged ACM requires a Procedure 5 Plan Approval prior to clean-up(See Procedure 5 Guidelines
l
STOPWORK NOTIFYOWNER SECURE STABILIZE POSTSIGNS ISOLATEWORKAREA SURVEY CHARACTERIZE WASTE OTHER
111 ❑ ❑ Ili ❑ ❑ ❑ ❑
Ordered Demolition:Attach a copy of the agency order
Agency Name Phone DateofOrda
Authorizing Person Title Date Ordered to Begin
Waste Information
WASTETRANSPORTER#1 Pacific Demolition WASTESTORAGESITE
Address 28690 Capano Bay CL Address
City Marilee State CA Zp 92584 City State_ Zip
WASTETRANSPORTER#2 LANDFILL El Sobrante
Address Address 10910 Dawson Canyon Rd.
City State ➢p Cry Corona Slate CA zip
Contractor Certification:All contractors or ownerloperator submitting this notification must sign this form
I cer8fy thalan individual trained in the provisions of regulationsAQMD Rule 1403 and ftAsbestcsNESHAP T#Ie 40 CFRPart 61 Subpart will beat site during thedandIkon or
renovation and evidence that the required training has been aocompl shed by this pagan A be avalablefor inspection durng normal business hcurs.I hmbycertify that all of the
intimation contained herein and information submitted with this notification is trueand oonect
Company Name Pacific Demolition TileclOvmerlOpPrralor CEO
Print Name ofOwnalOperator HarryGraun SignahrreofOwnalOperator „ wit--� Date 07/19/2016
Notification Fee: No notifications shall be considered received pursuantto Rule 1 unless!its amompanied by the required payment(Rule 301,TahleVl).Please make
check payable to'SCAQMD'.Fees are per nofication and vary according to the 2TOTALAMOUNTd asbestos removed or the demolition 2BUILOING SIZE.The RevisionAmount
fee is the difference between the new Project Size Feecategay and the original Projed Size Feecalegory(See Fee Information)
Project SizeFee: Fee Based on Project Size(sq it) Additional Fees
Additional Fee: 1,000 or less $59.37 ❑ Special Handling Fee $59.37
Total Fee Due: 1,001 to 5,000 $ 181.53 ❑ Revislon to Notification $59.37
5,001 to 10,000 $424.95 ❑ Returned Check Fee $25.00 ❑
10,001 to 50,000 $666.33 ❑ Planned Renovation $666.33 ❑
50,001 to 100,000 $965.68 ❑ Procedure 4 or 5 Plan $666.33 ❑
100,001 or more $1,609A6E]i Expedited 4 or 5 Plan $333.16 ❑
Attention
KeepThree(3)CopiesofThisNotificationFormfaryourrecords,topostattheworksite,andtoobtainadtydemoritlonpermit.SeeCialdm iaHes#handSale Q20U98275
that requires thatyou provide a copy of the demdii1on nofilcation to Building and Safety belie issuance of a demolition parra Forquestions call9M,196-2336.Forms,instructions and
Rule 1403cen be obdnedfiom theAQMD website al h#DlMnw.ammdeov.Please mail this signed original notification forth,fee,and any attachments to:ForUSPS:SCAQMD,
PO Box 55641,Los Angeles,CA 90074-5641;For ALL OTHER:Bank of Amerces Lockbox Services,Lockbox#55641,2706 Media Center Drive,Los Angeles,
CA 90065.Mailing saves time,money and reduces traffic and airpollution.
Project# 1
South CeastAir Duality Management District,Notification of Demolition or Asbestos Removal Form(2016.06)
Page 2 or 2