PMT16-03149 City of Menifee Permit No. PMT16-03149
29714 HAUN RD. Type: Residential Electrical
'(;kCCELA—> MENIFEE,CA 92586
Wk.- MENIFEE Date Issued: 09/30/2016
P E R M I T
SiteAddress: 26945 PINEHURST RD 26943. MENIFEE, Parcel Number: 338-061-006
CA 92586 Construction Cost: $3,000.00
Existing Use: Proposed Use:
Description of TEMP POWER POLE 100AMP
Work: ASSIGNED ADDRESS FOR TEMP POWER IS 26943 PINEHURST DR
Owner Contractor
LURA B CLOUGH NEWREAL ING
26945 PINEHURST RD 1120 W 9TH ST
MENIFEE, CA 92586 UPLAND,CA 91786
Applicant Phone:9099315280
RICK FORD License Number.633590
NEWIREAL INC
1120 W 9TH ST
UPLAND, CA 91786
Fee Description 9V Amount
Services, Switchboards,Control Centers& Panels 1 116.00
Building Permit Issuance 1 27.00
Additional Plan Review Building 148 148.37
GREEN FEE 1 1.00
General Plan Maintenance Fee-Electrical 1 5.80
$298.17
The issuance of this permit shall not prevent the building official from thereafter requiring the mmection of errors in the plans and
specifications or from preventing building 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.B1dg2errr*-Ternplate.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 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 13 License No 10 1 9 5*.Z'T By my signature below I acknowledge that except for my personal residence
Expires 9 -30' 1% Signature_ lAdAr 1 //51/( in which I must have resided for at least one year prior to completion of
A� 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
ci 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 cerfificate of consent of selfAnsure 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.IeRinfo.ca.Rov/calaw.htmL
Policy# Date
Ahave 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 n By my signature below I certify to each of the follomiling:I am the property
this permit is issued.M worker's coispensatlon insurance carrier and policy owner or authorized to act on the property owner's behalf.I have read this
numberare: 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 _� I building construction.I authorize representatives of this city or county to
Policy# 9 6 Expires 10 - 0— 1/a entertheabove 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
n I certify that in the performance of the work for which this permit is Issued, -701
1 sha 11 not employ any persons in any ma nner so as to become subject to the CITY BUSINESS LICENSE it ()�
workees 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 applica nt or futu re building occupant handle hazardous materia I 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 OkYes ci 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 District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATrORNEYS FEES for guidelines
CONSTRUCTION LENDING AGENCY o Yes cr 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 @4
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
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 mater' p ing.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 ON a Nc
Business and Professions Code).Any city or county that requires a permit to Date 30
construct,alter,improve,demolish or repair anystructure,PTIOTtO its
PROPERTY OWNER OR MHORIZED 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(RRPI
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 licensu re 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 RRPcertified firms and comply with
an 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 workthemselves or through their
o 1,as owner of the property,or my employee with wages as their sole employees.For more information about EPXs 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 1-800-424-LEAD(5323).
Code;The Contractor's State License Law does not apply to an owner of a ci An EPA Lead-Safe Certified Renovator will be responsible for this project
property who,through employees!or personal effort,builds or Improves t e
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:
0 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 your project d oes not com ply with EPA RRP ru le please fil I out the RRP
Acknowledgement.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION
-�/-`Menifee
DATE PERMIT/PLAN CHECK NUMBER tQW7 6-
TYPE: 0 COMMERCIAL )(RESIDENTIAL 0 MULTI-FAMILY 0 MOBILE HOME C) POOL/SPA O-SIGN
SUBTYPE: OADDITION OALTERATION ODEMOLITION WELECTRICAL OMECHANICAL
ONEW OPLUMBING (D RE-ROOF-NUMBER OF SQUARES—
DESCRIPTION OF WORK Ta_jhp L 'Rou Di!!��.
4�j
PROJECT ADDRESS 2— 6 Cl�4S ;0/4/eAugiT, #?,-D _�;c)A_) CT)e 9157,5m
ASSESSOR'S PARCEL NUMBER 2,;PS9-0(0k—WW LOT 5�51 TRACT
OWNER NAME U P,Ck, r4 0 U,q
ADDRESS 2— 5 /j_) f/VP_ 6vp_� 1 Fj
PHON E q "s, (jq —'R 0 C L� EMAIL
APPLICANT NAME FR /� F!v 1-z-T)
ADDRESS ?_0 \A,) 57 UP (A A-J CA 9 7t4
PHONEqCII Z_cp, EMAIL
coNTRAcrOR'S NAME Al�,U14 -eAL OWNERMUDER? OYESANO
BUSINESS NAME
ADDRESS 2-0 \A1, 9 T ro A 7
PHONE (70 q 1?3 1- jr 2,?o E MA I L @�,,/ eA k-- n,
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION Sq FT L SO FT
APPLICANT'S SIGNATURE DATE 2- 3_���
DEPARTMENT DISTRIBUTION CITY OF E BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PA�DAMOUNT CARD VISA/MC
AMOUNT I I OCASH OCHECK# 0 CREDIT
PLAN CHECK FEES PAD AMOUNT I I C)CASH 0 CHECK# 0 CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED 0 YES 0 NO DLNUMBER NOTARIZED LETTER 0 YES 0 NO
City of Memfee Building& Sofety Deportment 29714 ricun Rd. Menifee, CA 92586 951-672-6777
www.cityofmenifee.LIS Inspection Request Lille 951-246-6213
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