PMT16-03036 City of Menifee Permit No.: PMT16-03036
29714 HAUN RD.
'5ACCIELA> MENIFEE, CA 92586 Type: Residential Electrical
6-1 fllft�— MENIFEE Date Issued: 09/13/2016
P E R M I T
Site Address: 25710 CENTURION DR, MENIFEE, CA Parcel Number: 362-060-038
92584 Construction Cost: $200.00
Existing Use: Proposed Use:
Description of REPLACE DAMAGED POWER POLE, EXISTING PANEL TO BE REINSTALLED PER SOCAL EDISON
Work:
Owner Contractor
ROBERT&KIMBERLIND HURST
25710 CENTURION DRIVE
MENIFEE, CA 92584
Applicant License Number:
ROBERT&KIMBERLIND HURST
25710 CENTURION DRIVE
MENIFEE,CA 92584
Phone: 9512330864
Fee Description QtV Amount 1$)
Services, Switchboards, Control Centers&Panels 1 116.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Electrical 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 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.Bldg2ermlt-Templaterpt 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 ci 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 resided for at least one year prior to completion of
improvements covered by this permit.I cannot legally sell a stmcture that I
WORKEWS COMPENSATION DECLARATION have built as an owner-builder if It has not been constructed in its entirety by
o 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
this permit is Issued. www.Ie0nfa.ca.gov/calaw.html.
Policy# al%�_� —Date
o I have and will maintain workers compensation Insurance,as required by I`RbPERTY�OWNER OrAUAORIZED AGENT
section 3700 of the Labor Code,for the performance of the work for which ci 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
with all applicable city and county ordinances and state laws relating to
Carrier building construction.I authorize representatives ofthis city or county to
Policy# Expires enter the above Identified property for Inspection purposes.
(This section need not to be completed is the permit is for one-hundred Date �ZI311
PKOPERTY' 460 A�HORQED,
dollars($100)or less C'�/OWNEA OK'ADYHORIZED AGENT
ci I certify that in the performance of the work for which this permit is issued,
Ishallnotemplo 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?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ci Yes a No
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES Will the intended use of the building by the applicant or future building
AN D CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,001)),1 N 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 a Yes o No
I hereby affirm that under the penalty of perjury there is a constructilon 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) ci Yes ci No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCACIMD
permitting checklist.I understand my requirements under the State of
I hereby affirm under penalty of perjury that I am exempt from the Callfomia 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 aYes ci 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 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 a lleged exemption.Any violation of Section 7031.5 by residence or childcare facility to be RRP-certified firms and comply with
an Applicant for a perm it subjects the applicant to a civil pena ItV 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
a 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( I all of or( I 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 1-800424-LEAD(5323).
Code;The Contractor's State License Law does not apply to an owner of a 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. ci No EPA Lead-Safe Certified Firm is required for this project bemuse:
ci 1,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 you r project does not cc m p ly with EPA RRP rule p lease fi 11 out th e RRP
Acknowledgement.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION
4"Wenfee
DATE J//--3 PERMIT/PLAN CHECK NUMBERP"u -C5 505(.0
TYPE: OCOMMERCIAL XRESIDENTIAL CMULTI-FAMILY OMOBILEHOME OPOOL/SPA OSIGN
SUBTYPE: OADDITION OALTERATION 0DEMOUTION XELECTRICAL OMECHANICAL
ONEW OPLUMBING 0 RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK a.,
GIP, of Me nifee
12 Building' & Sal 9ty Dept.
PROJECTADDRESS 7/0 0 a,,, 4o-j?,r
ASSESSOR'S PARCEL NUMBER 2LQ-J0t00 -03!F LOT TRACT SEP 13 2016
OWNER NAME I- Ila f-5
ADDRESS 5--710 Wed
PHONE _7,3 �3 jq? (, 'Y EMAIL 1,7 C,/-1 4-5 4
APPLICANT NAME k"'M h �-e— rl wadr::5 r
ADDRESS
PHONE 47/A� EMAIL
CONTRACTOWS NAME OWNERBUILDER? )iDIESONO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ SO FT L SQ FT
APPLICANrs SIGNATURE DATE
OTYSTAFFUSEONLY
DEPARTMENT DISTRIBUTION u I Y OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE
AMOUNT PAID AMOUNT 0 CASH 0 CHECK# OCREDITCARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT 0 CASH 0 CHECK# 0 CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED 0 YES 0 NO DL NUMBER NOTARIZED LETTER 0 YES 0 NO
City of Allemfee Building& Sufety Deportment 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityof,menifee.us Inspection Request Line 951-246-6213