PMT16-03090 City of Menifee Permit No.: PMT16-03090
29714 HAIJIN RD. Type: Residential Electrical
<A—ccr=LA—> MENIFEE, CA92586
MENIFEE Date Issued: 10105/2016
P E R M I T
Site Address: 26202 BALDY PEAK DR,MENIFEE, CA Parcel Number: 338-251-025
92586 Construction Cost: $1,800.00
Existing Use: Proposed Use:
Description of MAIN PANEL UPGRADE 225A
Work:
Owner Contractor
ANNETTE CAIN VISION INSTALLATION
26202 BALDY PEAK DRIVE 5255 N EDGEWOOD DR-125
MENIFEE,CA 92586 PROVO, LIT 84604
Applicant Phone: 8887817074
KELLY BAKER License Number.853582
VISION INSTALLATION
5255 N EDGEWOOD DR-125
PROVO,CA 84504
Fee Description Qb[ Amount
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_B[dg_Permjt—Temp1ate.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION El I am exempt fram ficensure under the Contractore State License Law for the
I hereby affirm under penalty or pedury that I am licensed under provisions of following reason;
Chapter 9(commencing with section 7000)of Division 3 of the Business and By my signature below I acknowledge that. except for my personal residence in
Professions Code and my license is in full force and a which I must have resided for at least one year prior to completion of
License Class �10 License NO. . 3 5g2 improvements covered by this permIL I cannot legally sell a structure that I have
Expires Si...tum.-3—/D I dt, �rAr,P, built as an owner-building if it has not been constructed in its entirely by licensed
I )- — - contractors. I understand that a copy of the applicable law, Section 7D44 of the
WORKER&COMPENSATION DECIJ TGN� Business and Professions Code,is available upon request when this application is
A-1-hereby affirm under penalty of perjury one of the following declarations: submitted or at the following Web site:
I�have and will maintain a certificate of consent of self-insure for workers' http:/Aqww.leginfp.m.gov/mlaw.html.
compensation,issued by the Director of Industrial Relations as provided for by Date
Section 3700 of the Labor Code, for the performance of work for which this
permit is issued. Property Owner orAuthori7ed Agent
Policy# A-A&_ 90�� 0 By my Signature below, I certify to each of the following: I am the property
I have and will maintain workers' compensation insurance, as required by owner or authorized to act on the property owner's behalf. I have read this
)S1e:c,v,n 3700 of the Labor Code, for the performance of the work for which this application and the information I have provided Is correct. I agree to comply
permit is issued.My workers'compensation insurance canier and policy number are: with all applicable city and county ordinances and state laws relating to building
construction.I authorize representatives of this city or county to enter the above-
Carrier, ti 01 identi je property for iiiespectio purposes.
7116::� F�a 41L__ Date ?&t
Policy#q&02QLLQ- [!J__Expires 2�21 CM Z
Proloerilty OwndobtAuthorized Agem
(This section need not be completed if the permit is for City Business Ucense# 0SM910
one-hundred dollars($100)or law)
HAZARDOUS MATE IAL DECLARATION
__�certilfy that in the performance of the work for which this permit is issued,I
shall not emPID any persons in any manner so as to become subject to the Will the applicant or future building occupant,handle hazardous material or a
workers'compensation laws of Califiomia,and agree that if I should became mixture containing a hazardous material equal to or greater that the
subject to the workers'compensation provisions of Section 3700 of the Labor amountapecified on the Hazardous Materials Information Guide?
W1 y with th
Code,I shall Orthwithrpi I ose provisions. DYES NO
Appli uAewe;3�gf, Will the intended use of the building by the applicant or future6ullifing
occupant require a permit for the construction or modificatl6n from South
WAR..,_
NING: FAILURE TO SECURE WORKERS' Coast Air Quality Management District(SCAQMD)?See permitfing checklist
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL for guidelin s
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND DYES
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS P
($100,000), IN ADDITION TO THE COST OF COMPENSATION Will the proposed building or modifed facility be within 1000 feet of the outer
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF TH� boundary of a school?
LABOR CODE, INTEREST,AND ATTORNEYS FEES DYES 5WO
CONSTRUCTION LENDING AGENCY I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm that under the penalty of pedury them is a construction lending permitting checklist.I understand my requirements under the State of
agency for the performance of the work which this permit Is issued (Section California Health&Safety Code,Section 25505 and 25534 concerning
3097 Civil Code) hazardous matena re orting.
OWNER BUILDER DECLARATIONS DYE
'M 0 L_1__ (
I hereby affirm under penalty of perjury that I am exempt from the ConlraCtOT'S
License Law for the reason(s)indicated below by the checkmark(s)I have placed PF16PFRTY Ah&OR AUTHORIZED AGENT
next to the applicable item(s)(Section 7031.5.Business and Professions Code:
Any city or county that requires a permit to construct, alter,improve,demolish, EPA RENOVATION,REPAIR AND PAINTING(RRP)
or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the The.]EPA Renovation,Repair and Painting(RRP)Rule requires contractors
provisions of the Contractor's State License Law(Chapter 9(commencing with receiving compensation for Most work that disturbs paint in a pre-1 978
Section 7000)of Division 3 of the Business and Professions Code)or that he or residence or childcare facility to be RRP-certified firms and comply with
she is exempt from ficensure and the basis for the alleged exemption. Any required pracrices.This includes rental property owners and property
violation of Section 7031.5 by any Applicant for a permit subjects the applicant to managers who do the paint-disturbing work themselves or through their
a civil penalty of not more than($500).) employees.For more information about EPKs Renovation Program Visit:
0 1, as owner of the property, or my employees with wages as their sole www.epa.aovllead or contact the National Lead Information Center at
compensation,will do( )all of or( )porting of the work, and the structure is 1-800-424-LEAD(5323).
not intended or offered for sale.(Section 7044,Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property 0 An EPA Lead-Safe Certified Renovator will be responsible for this project
who, through employees' or personal effort, builds or improves the property.
proVided that the improvements are not intended or offered for sale.If,however, Certified Firm Name:
the building or Improvement is said within one year of completion, the Owner-
Builder will have the burden of proving that it was not built or improved for the Firm Cerfification No.:
purpose of sale).
0 1, as owner of the property an exclusively contracting with licensed 0 No EPA Lead-Safe Certified Firm is required for this project because:
contractors to construct the project(Section 7044, Business and Professions
Code:The Contractor's License Law does not apply to an owner of a property
who builds or improves thereon, and who contracts for the projects with a
licensed contractor(s)pursuant to the Contractors State License Law). If your project does not comply with EPA RRP rule please fill out the RRP