PMT16-02946 City of Menifee Permit No.: PMT16-02946
29714 HAUN RD. Type: Residential Plumbing
<A-CCELA—> MENIFEE,CA 92586
MENIFEE Date Issued: 09/0612016
P E R M I T
Site Address: 28941 LOIRE VALLEY LN, MENIFEE,CA Parcel Number: 364-124-025
92584 Construction Cost: $750.00
Existing Use: Proposed Use:
Description of INSTALL 25' U/G GAS LINE FOR FUTURE FIRE PIT
Work:
Owner Contractor
JUDY NORDSTROM EARTH-TONES LANDSCAPING
28941 LOIRE VALLEY LANE 8067 BRIDLE PATH CIRCLE
MENIFEE, CA 92584 RIVERSI DE, CA 92509
Applicant Phone: 9096850688
JUDY NORDSTROM License Number.418491
28941 LOIRE VALLEY LANE
MENIFEE,CA 92584
Phone:9513160728
Fee Description Amount
Building Permit Issuance 1 27.00
Inspections not specified 116 116.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Building 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 buillding 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.BIdq_Permft-Template.rpt Page 1 of 1
CITY OF IVIENIFEE
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 a I am exempt from licensure under the Contractor's 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 resid ed 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
a 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 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.IegJnfo.ca.Rov/calaw.htmI
this permit is issued.
Policy# LZe91,6
o I have 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 o 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 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 iden ified prope for inspection purposes
(This section need not to be completed is the permit is for one-hundred -Je Date
dollars($100)or less PROPERTY OWNER OR AUTHORIZED AGENT
u 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#
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the worker's 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
mixture containing a hazardous material equal to or greater that the
Applicant Date amounts specified on the Hazardous Materials Information Guide?
W.ARNING-FAILURE TO SECURE WORKER'S�OMPENSATION COVERAGE IS a Yes o No
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES Will the intended use of the building by the applicant or futu re 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
CONSTRUCrION LENDING AGENCY n 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 boundary of a school?
(Section 3097 Civil Code) o Yes o No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCACLMD
permitting checklist.I understand my requirements under the State of
I hereby affirm under penalty of perjury that I am exempt from the California Health&Safety Code,Section 25505 and 25534 concerning
Contractor's 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,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 Contractor's 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 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
a n Applica nt for a permit subjects the applica nt 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 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.eva.govIlead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-800-424-LEAD(5373).
Code;The Contractoes State License Law does not apply to an owner of a o 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. a No EPA Lead-Safe Certified Firm is required for this project because:
9A],as�,,ne,of the property a m exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractoes 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 RAP
Acknowledgement.
11 1, 1 111 m 1 1 1 lit
""Menifee
DATE PERMIT/PLAN CHECK NUMBER
TYPE: OCOMMERCIAL KRESIDENTIAL 0MULTI-FAMILY C' MOBILEHOME OPOOL/SPA OSIGN
SUBTYPE: 2<ADDITION OALTERATION ODEMOLITION OELECTRICAL OMECHANICA Cit b enifeg
ONEW OPLUMBING 0 RE-ROOF-NUMBER OF SQUARES_ buildingy V&Ifety Dept.
DESCRIPTION OF WORK SEP 0 2016
I PROJECT ADDRESS va SeA (��v 11^d
ASSESSOR'S PAI�CEL NUMBER Ld TRACT
OWNER NAME
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APPLICANT NAME Kllqr4cjr�n rii
ADDRESS 44-�-—(�fi
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PHONE 9S1-.1 li6 -61 MAIL jPelf-�-11 ///7
CONTRACTOR:S NAME 'r-r P c- d'WNER BUILDER? 0 YES 0
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BUSINESS NAME 15:91-"4�46, m ij� mio fkr)oj
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ADDRESS 01 /,
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PHONE EMAIL
CONTRAC LICENSE CLASSIFICATIOV C62 7
VALUATION$ L SOL FT
APPLICANT'S SIGNATURE JAJ DATE
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BURDING PLANNING EN I FIRE GREEN SMIP
INVOICE PAIDAMOUNT 0 CASH 0CHECK# OCREDITCARD VISA/MC_
AMOUNT l4q.50 I I 1�n-%o I
PLAN CHECK FEES PAIDAMOUNT 0 CASH 0 CHECK# 0 CREDIT CARD VISA/MC
LOWNER BUILDER VERIFIED 0 YES 0 No DILNUMBER NOTARIZED LETTER 0 YES 0 ND�
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityofimenifee.us Inspection Request Line 951-246-6213
CITY OF MENIFEE
BUILDING AND SAFETY DEPARTMENT
PLAN APPROVAL
City of Menifee
REVIEWED BY 91 La I�L-o Building & Safety D60
DATE SEP 0 6 2'016 ()
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'Approvalof theseplansshall not be construedtobea permftforor an Receivedg
approval of,anyvicilation of anyprovisionsof the lecleal,state or city LL
regulations and ordinances. This set of approved plans must be kept on the ILL
jobsite until completion. 0
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