PMT16-03449 City of Menifee Permit No.: PMT16-03449
29714 HAUN RD. Type: Residential Plumbing
<A—CCF-LAZ? MENIFEE, CA92586
MENIFEE Date Issued: 10120/2016
P E R M I T
Site Address: 28647 AMBORELLA WAY, MENIFEE, CA Parcel Number: 364-212-010
92584 Construction Cost: $979.00
Existing Use: Proposed Use:
Description of REPLACE EXISTING 50 GAL WATER HEATER IN GARAGE
Work:
Owner Contractor
ANDREWHOLMS AFFORDABLE WATER HEATERS AND PLUMBING
28647AMBORELLAWAY INC
MENIFEE,CA 92584 28358 CONSTELLATION ROAD#698
Applicant Phone:8553459087
DANIEL MATA License Number:627368
AFFORDABLE WATER HEATERS AND PLUMBING INC
28358 CONSTELLATION ROAD#698
VALENCIA, CA 91355
Fee Description 0tv Amount
Residential Water Heater 1 83.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1-00
General Plan Maintenance Fee-Plumbing 1 4.15
$115.16
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errors in the plans and
spedific:ations or from preventing builicling 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 mmmenced is suspended or abandoned for six months,shall expire,and fees paid shall be
forfeited.
AA Bidg_Permil-Templaterpt 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 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 se No. By my signature below I acknowledge that,except for my personal residence
Expires Z2Z�SigmrtuAr 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 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 decia 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
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 www.Ieoinf6.ca.gov/caIaw.htmI.
this permit is issued.
Policy# Date
PROPERTY OWNER OR AUTHORIZED AGENT
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 ci By 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 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
Carrier -mr, with all applicable city and county ordinances and stale laws relating to
k- building construction.I authorize representatives of this city or county to
Policy If VI(P�011AKOOExpires` enter the above 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
in I certify that in the performance of the work for which this permit is issued,
I shall not employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
worker's compensation laws of Califomiao agree that if I should become
q HAZARDOUS MATERIAL DECLARATION
subject to the wo ker's compe lon Wons of Section 3700 of the L bar
ct to t awn er's com of
,Isha rt With".0 e pr "S Will the applicant or future building occupant handle hazardous material or a
mixture containinga hazardous material equal to or greater that the
0 on the Hazardous Materials Information Guide?
FAILURE TO SECURE WORKER'S COM NSATION COVERAGE is c Yes o No
G. To U WO
WARNING.FAILURE SEC RE RKER COMPE
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 SECrION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidelines
CONSTRUCTION LENDING AGENCY Oyes 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) o Yes c No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMID
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 a pplicable item(s)(Section 7031.5 ciYes; 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 OWN ER OR AUTHORIZED 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(FIRM
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 7031.5 by residence or childcare facility to be RRP-certified firms and comply with
an Applica nt 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.Far mom information about EPA's Renovation Program visit:
compensation,will do( )all of or( )portion of the work,and the structure is www.epa.gay/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7D44,Business and Professions 1-800-424-LEAD(5323).
Code;The Contractor's State License Law does not apply to an owner of a a 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. o No EPA Lead-Safe Certified Firm is required for this project because:
o 1,as owner of the p roperty 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.
BUILDING & sAFETY PERMIT/PLAN CHECK APPLICATION
A�menifee
DATE \6 PERMIT/PLAN CHECK NUMBER "k-0 -
TYPE: jCOMMERCIAL 14RESIDENTIAL CMULTI-FAMILY OMOBILEHOME 0POOL/SPA OSIGN
SUBTYPE: OADDITION OALTERATION CDEMOLITION OELECTRICAL 0 MECHANICAL
ONEW 1APLUMBING 0 RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK
PROJECT ADDRESS -iAUAI Pi0ML_awJ\ e;�esm
ASSESSOR'S PARCEL NUMBER �,V L4 - 04%c;)-n I e�� LOT TRACT
PROPERTY OWNER'S NAME rnty of Menifee
ADDRESS Building & Safety Dept.
PHONE 4,4 EMAIL OCT 2 0 2016
APPLICANT NAME tAyk� Is d
ADDRESS CA r��AL5�04
PHONE EMAIL
CONTRACTOR'S NAME OWNER BUILDER? 0 YESA24NO
BUSINESS NAME 6��Lt JIAOS,
ADDRESS �D,(46kfA'�
PHONE okg-
%LA,5 - QOL�� — EMAIL _Ssj&�AP , cnr,\
CONTRACTOR'S STATE LIC NUMBER wns,('0`6 LICENSE CLASSIFICATION
VALUATION $ 2�w SCIFT //z x L SO FT
APPLICANT'S SIGNATURE Z DATE 116 vo
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS UCENSE NUMBEi�
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP Ac
INVOI '
'C PAIDAMOUNT 0 CASH 0
AMOUNT 11\13' \ 5 CHECK# 0 CREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT 0 CASH 0 CHECK# 0 CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED 0 YES 0 NO DLNUMBER NOTARIZED LE17ER 0 YES 0 NO
City of Menifee Building & Scfet,v DePortment 29714 Houo Rd. Menifee, CA 92586 951-672-6777
wwwxityafinenifee.us Inspection Request Line 951-246-6213
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