PMT16-03335 City of Menifee Permit No. PMT16-03335
29714 HAUN RD, Type: Residential Re-Roof
d:XCCELX_> MENIFEE. CA 92586
MENIFEE Date Issued 1011112016
P E R M I T
Site Address: 28560 MIDDLEBURY WAY, MENIFEE, CA Parcel Number: 339-111-016
92586 Construction Cost: $8,000.00
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING LAYERS, INSTALL NEW COOL ROOF SHINGLES
Work: CRRC#0890-0009
Owner Contractor
SHELLEY BERGERON HOUSETOP ROOFING
28560 MIDDLEBURY WAY 31760 BRIGGS ROAD
MENIFEE, CA 92586 MENIFEE, CA 92584
Applicant Phone:9516798369
RICH CARROLL License Number:371783
HOUSETOP ROOFING
31760 BRIGGS ROAD
MENIFEE, CA 92584
Fee Description Qtv Amount($)
Building Permit Issuance 1 27.00
Inspections not specified 98 98.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Building 1 4.90
$130.90
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errom in the plans and
specifications or from preventing bulliding 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.BidgPernnit Template.rpt 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 o I a in exempt from licensure under the Contra ctor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
LicenseClass 3�1 UcenseNo. 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 structure that I
WORKER'S COMPENSATION DECLARATIi�/ 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 applicartion 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. "w.leginfo.ca.gory/calaw.htni
Policy# Date
Xl�hiive and will maintain workees compensation insurance,as required by PROPERTY OWNER OR AUTHORIZED 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 of this city or county to
Policy :2Z4 Expires enter the above identified property for inspection purposes.
f
(This section need not to be completed is the permit is for one-hundred Date
dollars($100)or less PROPERTY OWNER OR AUTHORIZED AGENT
a 1 certify that in the performance of the work for which this permit is issued,
I shall not empi a ny persons in any ma nner 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 workees compensation provisions of Section 3700 of the Labor
Code,I shall fo
,��ivith ci�mply wilph4hose provisi Will the applicant or future building occupant handle hazardous material or a
Applicant 6�6.1_110 60y1=7Date /0////h� mixture containing a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING: RE TO SECURE WORKER'S COMPENSATION COVERAGE IS oYes ciNo
UNLAWFUeNDISHALL SUBJECTAN 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 ATTORNEYS FEES for guidelines
CONSTRUCTION LENDING AGENCY oYes ciNo
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 oNo
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and theSCAQMD
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 7032.5 ayes a 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,a Iso 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 IRRP)
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 Rcensure 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
an Applicant for a permit subjects the applicant to a civil penalty of not more required practices.This includes renta I property owners a nd property
than($500). managers who do the paint-disturbing work themselves or through their
a 1,as owner of the propeft or my employee with wages as their sole employees.For more information about EPA's Renovation Program Visit:
compensation,will do I I all of or I )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(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 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 because:
o 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 does not comply with EPA RRP rule please fill out the RRP
Acknowledgement.
& SAFETY PERMIT/PLAN CHECK APPLICATION
,,,J..LJ'Vlenifee
DATE Lo& PERMIT/PLAN CHECK NUMBER
TYPE: 0 COMMERCIAL a-RIEESIDENTIAL 0 MULTI-FAMILY 0 MOBILE HOME 0 POOL/SPA 0 SIGN
SUBTYPE: OADDITION CIALTERATION ODEMOLITION OELECTRICAL OMECHANICAL
ONEW OPLUMBING '�rCE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK
PROJECTADDRESS o
ASSESSOR'S PARCEL NUMBER LOT TRACT QP45a
';1' 0 Menifee
OWNER NAME QuildioY4 Unfety Dept.
ADDRESS n4c
PHONE 3 0 L e&? EMAIL OCT 2 —
APPLICANT NAME eQ eel Received
ADDRESS
PHONE S-03'_— Z 711 EMAIL
CONTRACTOR'S NAME OWNERBUILDER? OYESMNO
BUSINESS NAME
ADDRESS IZA -
PHONE 7,11 EMAIL ,Z C a�l
"p flZe�2 I S —
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ ef/� C-)Loo SO FT L SO FT
I APPLICANTSSIGNATURIF DATE
CITY STAFF USE ONLY
DEPARTMENT DISTRIBUTION SMIPTk CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN
INVOICE PAIDAMOUNT
AMOUNT jj'W OCASH OCHECK# 0 CREDIT CARD VISAIMC
PLAN CHECK FEES PI IDAMOUNT 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 Menifee Building& Safety Deportment 29714 Houn Rd. Menife�e, CA 92586 951-672-6777
www.cityofirenifee.us Inspection Request Line 951-246-6213
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