PMT16-03376 City of Menifee Permit No.: PMT16-03376
29714 HAUN RD. Type: Residential Re-Roof
<ACCF_L:^_31 MENIFEE, CA 92586
MENIFEE Date Issued: 10/13/2016
P E R M I T
Site Address: 29937 GIFHORN RD, MENIFEE, CA Parcel Number: 339-313-002
92584 Construction Cost: $12,286.05
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING LAYERS, INSTALL NEW COOL ROOF SHINGLES
Work: CRRC#08913-0009
Owner Contractor
JOHN RODGERS PETERSEN-DEAN INC
29937 GIFHORN ROAD 39300 CIVIC CENTER DRIVE
MENIFEE,CA 92584 FREMONT,CA 94538
Applicant Phone:5103716500
JENNY ENCISO License Number 468117
PETERSEN-DEAN INC
39300 CIVIC CENTER DRIVE
FREMONT, CA 94538
Fee Description 9ty 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 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 Bidg_Pemit—Template.rpt Page 1 of I
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 se' !on 7000)of Division 3 of the Business and a I am exempt from licensure under the Contractoes State License Law for
Professions Code and my licens is ln�l rce d effect. the following reason;
A U
Li e
License Class— U-ense Byrnysignature below I acknowledge that except for my personal residence
Expires ?21 SigInIture )i— _V in which I must have resided for at least one year prior to completion of
I 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
o I hereby affirm under Pena Ity of perjury one of the following decla rations: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
cam 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
this permit is issued. www.IeAInfo.ca.Roy/caIaw.htmI.
,7,h,Pol # Date
, PROPERTY OWNER OR AUTHORIZED AG ENT
ve and will maintain workees compensation insurance,as required by
section 3700 of the Labor Code,for the performance of the work for which -iqEry my signature below I certify to each of the following:I a in the property
this permit is issued.My worker's compensation insurance carrier and policy owner or authorized to act an the property ownees behalf.I have read this
number ar appli tonan the Winformation I have provided is correct I agree to comply
'flc le city dco ty ordinances and state laws relating to
'Spe-1 in ut
Carrier with all applic le c
building con r in .I autho ze representatives of this city or county to
Policy�IX7M N4 9 0 Expires M_ 1:1 enter the p ove tifie operty for inspection purp .
I 10sfs I
(This section need not to be completed is the permit is for one-hundred Z", Date 10 11?1 11 Le
dollars($100)or less W 0 0 U __F-F
PROPERTY0 kEgOlt AUTAURIZED AGENT
o I certify that in the performance of the work for which this permit is issued,
I shall not em ploy any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
worker's compensatio0law Kliflif, d agree that if I should become HAZARDOUS MATERIAL DECLARATION
so "'
subject to the worke cam, nsatio provisions of Section 3700 of the Labor
,t7
Code,I shall forth h mpl ith)ose provisions. Will the applicant or future building occupant handle hazardous material or a
mixturecont Ining a hazardous material equal to or greater that the
Applicant —Date a amountss
fled on the Hazardous Materials Information Guide?
WARNING:FAILUFIETO�EU Roc
L �UIRE"OFKER'S COMPENSATION COVERAGE 15 0yes I
UNLAWFUL,AND SHALL U ECTAN EMPLOYER TO CRIMINAL PENALTIES Will the intended use of the building by the applicant or luture 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 QpIlty Management District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguidel es
CONSTRUCTION LENDING AGENCY ciYes 7ho
I hereby affirm that under the penalty of perjury there is a construction Will the pro P sed building or modified facility be within 1000 feet of the
lending agency for the performance of the work which this permit is issued outer bou ary of a school?
(Section 3097 Civil Code) o Yes ;7N,
OWNER BUILDER DECLARATIONS I have read the Han rdous Material Information Guide and the SCAOM D
he� I u n Jeq uIrements under the State of
lifta
I hereby affirm under penalty of perjury that I a m exempt from the P r 'I cht& fi=,Z�-11
MImft1rn1na1c Sect! n 25505 and 25534 concerning
Contnctor's License Law for the reason(s)indicated below by the hazard knk,./
checkma rk(s)I have placed next to the applica ble item(s)(Section 7031.5 oYes VN�7
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 PROPERTYC& ERORA� ORIZED 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 Contractoes State EPA RENOV N REPA R NO PAINTING RRIP
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the The EPA Renovation,Repair and Painfing(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 7031.5 by residence or childcare facility to be RRP-certified firms and comply with
an Applica nt for a perm it subjects the applica nt to a civil pena Ity 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
o 1,as owner of the property,or my employee with wages as their sole emplayees.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.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 in 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 sa le. a No EPA Lead-Safe Certified Firm is required for this project because:
o 1,as owner of the property a an exclusively contracting with licensed
contra ctors to construct the project(Section 7044,Business a ad 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.
N MECKAPPOICATION
n i fee
DATE PERMIT/PLAN CHECK NUMBER 0�nMIQ -C),=1(j2
TYPE: COMMERCIAL ORESIDENTIAL [:]MULTI-FAMILY [-]MOBILE HOME [-]POOL/SPA E]SIGN
SUBTYPE: DADDITION [:]ALTERATIO E]DEMOLITION []ELECTRICAL []MECHANICAL
ONEW [:]PLUMBING PRC-ROOF-NUMBER OF SQUARES 25 4: il
I
DESCRIPTION OF WORK gf-V(n�-- vfm�t, e_-� no chnv sb;.rNrde Av PV) th T.-o-sh
1 14
PROJECT ADDRESS
I .�) G,'i Ori ny y) Ad-ey &LAW10. Md
ASSESSOR'S PARCEL NUMBER 00=1 LOT TRACT n!Lee
F
C!"O!;1e ety 0
Builaj�g� a e
PROPERTY OWNER'S NAME 30nn ocyjatfs
n (� I. . I — 12�"l 3 2016
ADDRESS 2 � 15 1 1 ffij\yn 12A. Mh)
PHONE (IN �70 I- 45D2 EMAIL Rpcpivpd
APPLICANT NAME P FAaUS C-)
ADDRESS IQ (A ONI)fade-> CA �25
PHONE EMAIL -P
QeT cbo
CONTRACTOR'S NAME C!��A_-cfsedp Mc. AWRIFIR RINI'nl,:R,> r-i Y q r:7K,n
BUSINESS NAME
ADDRESS
V*�\I-ff',,A-e CA
PHONE �jr)JY27U - A�JD EMAIL
CONTRACTOR'S STATE LIC NUMBER A LICENSE CLASSIFICATION G 39
VALUATION$ 12 , 2
L SQ FT
APPLICANIT'S SIGNATURE DATE in I s lj( 0
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE I GREEN SMIP
INVOICE PAID AMOUNT
AMOUNT ?Qq0 I 1k,:a!0q0 ICCASH OCHECK# C'CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT I ,
I I CASH CJCHECK# CREDIT CARD VISA/MC
FoW—NER BUILDER VERIFIED 0"YES 0 NO DIL NUMBER NOTARIZED LETTER 0 YES 0 NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.citvotmenifee.us Inspection Request Line 951-246-6213
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