PMT16-03391 City of Menifee Permit No.: PMT16-03391
29714 HAUN RD.
<A_CCELX_-' MENIFEE, CA 92586 Type: Residential Re-Roof
MENIFEE Date Issued: 10114/2016
P E R M I T
Site Address: 29672 SINGING WOOD LN, MENIFEE, Parcel Number: 338-224-020
CA 92586 Construction Cost: $8,490.00
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING LAYERS, INSTALL NEW COOL ROOF SHINGLES
Work: CRRC#0890-0012
Owner Contractor
SAMANITHAJOHNSON GARDNER ROOFING COMPANY
29672 SINGING WOOD LANE 594 WEST SEVENTH STREET
MENIFEE,CA 92586 SAN JACINTO,CA 92382
Applicant Phone:9516542794
LEE BLOOMER License Number.,528309
GARDNER ROOFING COMPANY
594 WEST SEVENTH STREET
SAN JACINTO, CA 92382
Fee Description Oty 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.
M_Bldg_PermitTemplate.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).
Chapter!)(commencing with section 7000)of Division 3 of the Business and o I am exempt from licensure under the Contractors State License Law for
Professions Code and my license is in full force and effect. the following reason:
LicenseClass— License No. By my signature below I acknowledge that,except for my personal residence
&70q
Expires 12--20142 Sign,toiiij���� in which I must have resided for at least one year prior to completion of
WORKER'S COMPENSATION DECLARATION !in provements covered by this permit.I cannot legally sell a structu re that I
have built as an owner-builder if it has not been constructed in its entirety by
o I hereby affirm under penalty of perjurV*one of the following decla nations: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 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.leginfo.ca.goy/calaw-litmi.
Policy N '70-7 7,1 SX—I(o Date
o I have 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 u 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 ownees behalf.I have read this
number are; application and the information I have provided is correct.I agree to comply
Carrie with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# —Expire, o Lo enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred
dollars($100)or less Date
ci I certify that in the performance of the work for which this permit is Issued, PROPERTY OWNER OR AUTHORIZED AGENT
Ishallnotempi any persons in any manner so as to became 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 shal w- ose provisions. Will the applicant or future building occupant handle hazardous material or a
Applicant ate mixture containing a hazardous material equal to or greater that the
-rdy-4 amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS a Yes a No
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($10 Will the intended use of the building by the applicant or future building
ON,DAMAGES AS PROVIDED FOR
ADDITION TO THE COST OF COMPENSATI 01000),IN occupant require a permit forthe construction or modification from South
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES Coast Air Quality Management District(SCACMD)?See permitting checklist
for guidelines
CONSTRUCTION LENDING AGENCY Dyes ONO
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) ciYes oNo
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm under penalty of perjury that I am exempt from the permitting checklist I understand my requirements under the State of
Contractor's License Law for the reason(s)indicated below by the California Health&Safety Code,Section 25505 and 25534 concerning
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 hazardous material reporting.
Business and Professions Code).Any city or county that requires a permit to oYes a No
construct,alter,Improve,demolish or repair any structure,prior to its Date—
issuance,also requires the applicant for the permit to file a signed statement PROPERTY OWNER OR AUTHORIZED AGENT
that he or she Is licensed pursuant to the provisions of the Contractoes state EPA RENOVATION,REPAIR AND PAINTING(RRP)
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
and the basis for the alleged exemption.Any violation of Section 7031.5 by receiving compensation for most work that disturbs paint In a pre-1978
an Applicant for a permit subjects the applicant to a civil penalty of not more residence or childcare facility to be RRP-certified firms and comply With
than($500). required practices.This includes rental property owners and property
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 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.ecia.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 Contractoes State License Law does not apply to an owner of a
property who,through employees'or personal effort,builds or improves the ci An EPA Lead-Safe Certified Renovator will be responsible for this project
property provided that the Improvements are not intended or offered for Certified Firm Name:
sale.if,however,the building or improvement is said within one year of
completion,the Owner-Builder will have the burden of proving that it was Firm Certification No.:
not built or improved for the purpose of sa le. o No EPA Lead-Safe Certified Firm is required for this project because:
o 1,as owner of the property a in exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractoes State License Law does not apply to an owner of a If your project does not comply with EPA RRP rule please rill out the RRP
Acknowledgement
I)I kq IQ Va I C,jyj I I a%FAI k
1,"Menifee
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CONTRACTOR'S NAME (Ogranm 40.6�
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CONTRACTOR'S STATE LIC NUMBER UCENECLASEIRCATION
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APPLICANT'S SIGNATURE DATrz
DEPARTMENrOORBLMON SM,p WEER
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INVOICF- BAJDAMOUNT
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OMER BUILDERVERRED 0 16B 0 No E)LNUMBER NCFTARZED LEMER 0 MB 0 NO
Clty of Menifee Building&Wety Department 29714 Haun Rf Menifee� C4 92586 951-672-6777
www.cityofmenifee us Inspection Fbquest Line 951-246-6213
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