PMT16-03738 City of Menifee Permit No.: PMT16-03738
29714 HAUN RD.
-(;kCCELjA_> MENIFEE, CA 92586 Type: Residential Plumbing
MENIFEE Date Issued: 11/2112016
P E R M I T
Site Address: 25583 CEDAR RIVER CT, MENIFEE, CA Parcel Number: 335471-012
92585 Construction Cost: $700.00
Existing Use: Proposed Use:
Description of REPLACE 50 GAL WATER HEATER, LOCATED IN GARAGE
Work:
Owner Contractor
POE LAM YUEN INTER-CITY ENERGY SYSTEMS INC
25583 CEDAR RIVER CT 1175 N DEL PLACE
MENIFEE, CA 92585 ONTARIO,CA 91764
Applicant Phone:9097855075
TERESA DINTERMAN License Number:587709
INTER-CITY ENERGY SYSTEMS INC
1175 N DEL PLACE
ONTARIO, CA 91764
Fee Description Qtv Amount(S)
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
$115.15
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.13k1g_Permft_Template.rpt Page 1 of I
CITY OF MENIFEE
LICENSED DECLARATION property who builds or Improves thereon,and who contracts forthe 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 underthe Contractor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
LicenseClass C.!:�Lo License By my signature below I acknowledge that,except for my personal residence
Expires ;�/2151'17!i/Signature in which I must have resided for at least one year priorto completion of
Improvements covered by this permit.I cannot legally sell a structure that I
WORKER'S COMP4ATION DECLARATION 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 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.gov/calaw.htmi.
Policy# Date
PROPERTY OWNER OR AUTHORIZED AGENT
Vhave 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 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
Carrier2t:in-a, with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# Wcngn Expires h enter the above' tilled property for inspection purposes.
(This section need not to be completed is the permit_ZroZhun 7red f��Dte
dollars($100)or less =-'IT,
PROPEF(ry'OWNER OR A13—n-IORIZEDAGENT
o I certify that in the performance of the work for which this permit Is Issued, 0;/a ,
I shall not employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE It
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the worker's 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
Applicant Date mixture containing a hazardous material equal to or greater that the
amounts sp!e
,5;i1fied on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS o Yes 0
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES r
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 Qua] anagement District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for gold 11 21"
CONSTRUCTION LENDING AGENCY a Yes 7NO
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 1000 Net of the
lending agency for the performance of the work which this permit is issued outer bound of a school?
(Section 3097 Civil Code) o Yes 070
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 CaIifomiaHeeh,',8,,1 et'yt2cle,Section 25505 and 25534 concerning
a
a r:f
Contractor's License Law for the reason(s)indicated below by the hazardous , e po rig.
checkmark(s)I have placed next to the applicable Item(s)(Section 7031.5 ciYes
Business and Professions Code).Any city or county that requires a permit to �Dte
construct,alter,improve,demolish or repair any structure,prior to Its PROPERTY OW19ER 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(RRPj
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 ficensure 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 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 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.goyllead 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 o 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 forthe 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.
CITY OF MENIFEE
29714 Haun Road PLCK No
Date: Da
Menifee, CA 92586 it 1pa 11(o
Phone: (951)672-6777 =Amount Amount
ft
Fax:(951)679-3843 _J
r C
CM lk V.
Building Combination Permit
To Be Cornpleted YAPP11cant
Legal DeMplion: & Planning Case: L 11 R, V.
PrapertyAdd Assessor's Parcel Numb I er
me:
Projec nant Na 2� 71-0 r,30
Ile- 11 22 to Z_4M Unit Floorlk
_�6_e
j a
_ _kq, Phone No.07-,!:Z-Q i JFaxNo.
Property zl� -
Owner Addr Opt c-�, K6 __Ifun"Number
No- Fax No.
NN M& J'qll--71�-4- 0-2si
Applicant 42 110 /e�/ Urift Number Zp Code 917661
Lmsil Addresso.
Name* Phan �No.
e��W <
Contractor Ad Mp Code
IPL
Conu2W�M,Susfnpiqs Eii;auise No. rombnootor's c:
_e2tate or !Irrfia Ucense.
e9 <4
Numt;erorSquares:
Square Footage
Desorption of Wo Icoitofwo
7ppllcanFs'Sgnat Date:
Z—(e
79 Be Completed ByCity Staff Only
Indicate As R-Received or M-NotApplicable
5 Completes sets of fully dimensioned,drawn to sale plans which includw 1 wt of documents which include
0 Title Sheet [3 Elevations E3 Electrical Plan 13 GeoTsch/Solls Report(oncd only)
[3 Plot I Site Plan chemical Plan [] Title24 Energy(on 8'Ax 11)
[3 structural Calculatsorte
El Foundation Plan E3 Plumbing Plan El Single Line diagram forelec.services over4l)DAMP
Floor Plan [3 Structural Frarning Plan&Details [3 Shoring Plan Sound Report-Residential
M Roof Plan E3 me
Cross Section
Class Code: New Construction Alteratiorr AddttiW McansfMathods
n,a Repair- Retmflt7 HRevislonloExisurigPeftlRoQuIred? YES NO
Proposed Building Use(s): wnd-,,,k Typ-H H Existing Building Use($):
#Buildings: #Units: #Stories: Will the Building Have a Basement? Y of N
Bldg.Code Occupancy Group Indicate It YESorNQ tndimtealt Geo-tech.Haz.Zone
At Project Indicate sprinklered that apply., Coastal Zone
Completion: Construction I
Type(s): C 0 Noise Zone
lReq I H Usted on Historic Resources Inventory
CITY PLANNING STAFF ONLY
APPROVALS: costal Commiss Arch.Review Board I I Landmark Comm. I I Planning Comm.lZoning Adminis tar
city Proj Elec.Vehicle Chargerl I Landmark SeismiiaRetrolit bruma Uase:.M:ag_
Fee Exempt: I I I Model=
Expedite Project(s): Child Cam City Project Green Building I I Lwdmarki I Affondzbie Housing
For Staff Use Only
Building/Safely Pemnitsp I I EPvv C�.W
THANK YOU FOR HELPING US CREATE A BETTER COMMUNITY
CITY OF MENIFEE
Department of Building and Safety
Contractor Declaration
LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under the provisions of Chapter 9
(connecting with Section 7000)of Division 3 of the Business and Professions code and my license is in full force and effect.
License Class: (2 -1 0
License No:— -7-709
Exp.Date Contractor:_:Qffer-C Lif ifgq-L4,5 A-PrU-
1 C/0 d
F1 OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the
following reason: (See 7031.5 Business and Professions code. Any City or County which requires a permit to construct,alter,improve,
demolish or repair any structure prior to its issuance,also requires the applicant for such permit to file a Signed statement that he or she
is licensed pursuant to the provisions of the Contractors License Law(chapter 9[commencing with Section 7000]of Division 3 of the
Business and Professions Code)or that he or she is exempt there from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500.001:
rl 1,as the owner of the property,or my employees with wages as their sole compensation,will be the work,and the structure is not intended
or offered for sale(See.7044,Business and Professions code: The Contractor License Law does not apply to the owner of property who
builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such
improvements are not Intended or offered for sale. If,however,the building or improvement is sold within one year of completion,the
owner-builder will have the burden of proving that he/she did not build or improve for the purpose of sale).
1.as owner of the property,am exclusively contracting with license contractors to construct the project(Sec.7044 Business and
Professions Code: The Contractor License Law does not apply to an owner of property who builds or improves thereon,and who
contracts for such projects with a contractor(s)license pursuant to the Contractors License Law).
C3 I am exempt under See. B&P.C.for the reason
Date: Owner:
WORKERS COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations:
n I have and will maintain a certificate of consent to self-insure for worker compensation,as provided for by Section 370 of the Labor Code,
for the performance of the work for which this permit is issued
'fI have and will maintain workers compensation insurance,as required by Section 3700 of the Labor Code,for the performance of the work
or which this permit is issued. My Workers Compensation Insurance carrier and policy Number are:
Carrier: ako;A -41� Policy Number: j,2 <�/o el,�,
(This section need not be completed if the permit is for one hundred dollars($100.00)or less.
I certify that in the performance of the work for which this permit is Issued,1 shall not employ any person in any manner so as to become
subject to the workers compensation laws of California,and agree that if I should become subject to the workers compensation provisions of
Sec.3700 of the Labor Code.I shall forthwith comply with those p S.
Date: Applicant:
WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO
CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF
COMPENSATION,DAMAGES AS PROVIDED FOR IN SEC.3706 FOR THE LABOR CODE,INTERST,AND ATTORNEY FEES.
CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction-lending agency for the performance
of the work for which this permit is issued(Sec.3097,Civic C.).
Lender's Name:
Lender's Address:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify that I have read this application and state that the above
information is correct. I agree to comply with all City ordinances and state laws relating to building construction,and hereby authorize
representatives of the City to enter upon the above mentioned property for inspection purposes.
x
Signature of ApplicantlAgent Print Applicant/Agent Name Date
INSPECTION INFORMATION:Work may proceed only atthe direction of the field inspector.�To request an inspection of work completed,call
the number(951)672-4777. Inspection request must be called in the day before to assure next day inspections.
City of Menifee
:3utiding & Safety Dept.
WEATHERIZATION WER-Cr1YEnRGYSYMN19
NOV �1 FlUlt
e v(a d
Authorization to Obtain and Sign Permits and Business License for Contractor
I hereby authorize Teresa Dinterman to act on my behalf in obtaining permits and Business
License for the building and safety department of which city we are working in and to sign said
permit applications and Business License for me. I am properly licensed as required by the State
of California.
I assurnefull responsibility underthe lawfor permitstaken byTeresa Dinterman, as authorized
by this document to act in my behalf.
I understand that notarization is required and is herein included.
This authorization shall continue in force until the Department of Building and Safety for whom
we are working in is notifled, in writing by me,that this authorization is cancelled. I understand
also,that the cancellations,should it be necessary requires notarization also.
Company Name:Inter-City Energy Systems
State Contractors Lic�jnse#587709
Teresa Dinterman,Authorized Agent
Richard Villaspnor,f resident, License Holder
Date ///� fl(�)
12252 McCann Drive,Santa Fe Springs,California 90670 1175 N.Del Rio Place,Ontario,California 91764
(800)906-3911-(562)777-1142-FAX(562)777-0822 (909)753-5075-FAX(909)758-5084
CL4622252 CL9587705
CALWORINIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL OODE 1189
........ ......
A notary public or other ofter completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached,and not the truthfulness,accuracy,or validity of th at document.
State of California
County of-,:a,) 23 G�zznkno_/�
on before me, Louis James Hubaud, Notary Public
Date Here Insert Name and Title of th� Officer
personally appeared hj4flalyo
Name(A)of Slgner(4
who proved to me on the basis of satisfactory evidence to be the person(p) whose name(q)iWare,
subscribed to the within instrument and acknowledged to me thatNt&ha/they executed the same in
Wher/their authorized capacityCles),and that by&heritheirsignature14 on the instrument the persorig
or the entity upon behalf of which the person(so-acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is.true and correct.
—-- - - - - WITNESS my hand and official se
LOUIS JAMES HUSAUD
Carrimission 2129699
Note Z
ary
I v P.abir California Z Signature
San Bernardino County Signature of Notary Pubfic
My Comm.Expires Nov 6.2019
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document
Description of Attached Document e)(::-) Piz;"n,r
Title or Type of Document: 12 Oryaq Y2,6-t ;ro 0131bi-J Document Date:
Number of Pages: — Signer(s) Other Than Named Abovw.
Caparilty(iies) Claimed by Signer(s)
Signees Name: Signers Name:
0 Corporate Officer-Title(s): 0 Corporate Officer- TItle(s):
0 Partner- 0 Limited 0 General 0 Partner - 0 Limited 0 General
0 Individual 0 Attorney in Fact 0 Individual 0 Attorney in Fact
0 Trustee 0 Guardian or Conservator 07rustee 0 Guardian or Conservator
0 Other: 0 Other:
Signer Is Representing: Signer Is Representing:
@2014 National Notary Association -www.NafionalNotary.org-1-800-US NOTARY(J-BaO-876-6827) Iten'1415907
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