PMT16-03290 City of Menifee Permit No.: PMT16-03290
29714 HAUN RD.
<Xccr=LA—> MENIFEE,CA 92586 Type: Residential Electrical
MENIFEE Date Issued: 10/0612016
P E R M I T
Site Address: 25144 SILVERWOOD LN, MENIFEE, CA Parcel Number: 339-430-028
92584 Construction Cost: $0.00
Existing Use: Proposed Use:
Description of HOURLY INSPECTION TO INSPECT ELECTRICAL PANEL TO RE-ENERGIZE
Work:
Omer Contractor
ROBERT CAMPBELL
25144 SILVERWOOD LANE
MENIFEE,CA 92584
Applicant License Number:
ROBERT CAMPBELL
25144 SILVERWOOD LANE
MENIFEE,CA 92584
Phone:7146036403
Fee Description QtV Amount($1
Building Permit Issuance 1 27.00
Inspections not specified 129 129.07
$156.07
The issuance of this permit shall not prevent the building official from thereafter requiring the cerrection 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.S1dg_Permil_Template.rpt Page I of 1
CITY OF IVIENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts forthe projects
with a licensed contractor(s)pursuant to the Contractors State License Law).
I hereby affirm under penalty of perjury that I am under provisions of
Chapter9(commencing with section 7000)of Division 3 of the Business and o I am exempt from ficensure underthe Contractor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
License Class Utcense 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 ca root 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-insu re for worker's 7044 of the Business a nd Professions Code,is available upon req uest when
com pensation,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.IeRInfo.ca.Rov/caIaw.htmI.
this permit is issued.
Policy# PROPERTY OWNER OR AUTHORIZED AGENT Date
a I have and will maintain worker's compensation insurance,as required by
section 3700 of the Labor Code,for the performance of the work for which u By my signature below I certify to each of the following:I am the property
this permit is issued.My workees 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 of this city or county to
Policy# Expires ent he ab a ide ti roperty for'ns n purposes.
(This section need not to be completed is the permit is for one-hundred 2rnate Z
RQ R40W
dollars($100)or less N1f'E'1RVRAUTH9&IZED AGENT
o I certify that in the performance of the work for which this permit is issued, 7r'
I shall not employ any persons In any manner so as to become subject to the CITY BUSINESS LICENSE#
worker's compensation lam of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the workees 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 oYes allo
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 TOONE 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 Qua lity Management District(SCAQMID)?Sea permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguidelines
CONSTRUCTION LENDING AGENCY o Yes o 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) oYes aft
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 2S534 concerning
Contractoes 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 a No
Business and Professions Code).Any city or county that requires a permit to Date
conAruct,alter,improve,demolish or repair any structure,prior to its PROPERTY OWNER OR AUTHORIZED AGENT
issuance,a Iso requires the applicant for the permit to file a signed statement
that he or she Is licensed pu rsuant to the provisions of the Contractoes State EPA RENOVATION,REPAIR AND PAINT] G(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 licensure receiving compensation for most work that disturbs paint in a pre-1978
and the basis for the alleged exemption.Any violation of Section 70315 by residence or childcare facility to be RRP-certifted 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($500). managers who do the paint-disturbing work themselves or through their
u 1,as owner of the property,or my employee with wages as their sole employees.For more information about EPA's Renovation Program visit:
compensation,will do( )all of or( )portion of the work,and the structure is www.epa.goy/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-800-424-LEAD(S323).
Code,The Contractoes State License Law does not apply to an owner of a o An EPA Lead-Safe Certified Renovator will be responsible for this project
property who,through employeee or personal effort,builds or improves the
property provided that the improvements are not intended or offered for Certified Firm Name;
sale.If,however,the building or Improvement is sold within one year of Firm Certification No.:
completion,the Owner-Builder will have the burden of proving that it was
not built or improved for the purpose of sale. o No EPA Lead-Safe Certified Firm is required for this project bemuse:
a 1,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contracter's State License Law does not apply to an owner of a If your project does not comply with EPA RRP rule please fill out the RRP
Acknowledgement
& SAFETY PERMIT/PLAN CHECK APPLICATION
Menifee
DATE PERMIT/PLAN CHECK NUMBER em
TYPE: 0 COMMERCIAL I/RESIDENTIAL 0 MULTI-FAMILY 0 MOBILE HOME 0 POOL/SPA 0 SIGN
SUBTYPE; 0 ADDITION 0 ALTERATION 01 DEMOLITION VELEcTRICAL 0 MECHANICAL
ONEW OPLUMBING 0 RE-ROOF-NUMBER OF SQUARES—
DESCRIPTION OF WORK
Menifee
PROJECTADDRESS
Safety Dept.
ASSESSOR'S PARCEL NUMBER ot�q LOT TRACT OCT ) 6 2016
OWNERNAME ep"11 V4 ecejv(&(j
ADDRESS Z/a
PHONE '�7/!�) 60 3 EMAIL
APPLICANT N�ME
ADDRESS
PHONE EMAIL
CONTRACTIOR'S NAME OWNERBUILDER? OYESONO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ SO FT L SQ FT
APPLICANT'S SIGNATURE 6-Y DATE 10-0�1 —IVI
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BU INESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE I 15U .0_11 PAIDAMOUNT
AMOUNT I JOCASH 0 CHECK# 0 CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT 0 CASH 0 CHECK It OCREDITCARD VISA/MC
[OWNER BUILDER VERIFIED OYES 0 NO DLNUMBER NOTARIZEDUETTER 0 YES 0 NO
__11
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityofmenifee.us Inspection Request Line 951-245-6213