PMT16-04068 City of Menifee Permit No. PMT16-04068
29714 HAUN RD. Type: Commercial Alteration
<A-CCIEG� MENIFEE, CA 92586
MENIFEE Date Issued: 1211312016
P E R M I T
Site Address: 28089 BRADLEY RD, MENIFEE, CA Parcel Number: 337-302-014
92584 Construction Cost: $0.00
Existing Use: Proposed Use:
Description of HOURLY INSPECTION FOR C OF 0"GRACIE'S LUNCHBOX"
Work:
Owner Contractor
HUB PROPERTIES
29826 HAUN ROAD,#305
MENIFEE, CA 92586
Applicant License Number:
MENIFEE, CA
Fee Description Qtv Amount M
Building Permit Issuance 1 27.00
Inspections not specified 129 129.07
$156.07
The issuance of this permit shall not prevent the building official from thereafter requidng 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_Perrnft-TempIate.rpt Page 1 of 1
CITY OF MEN I FEE
LICENSED DECLARATION property who builds or improvu 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 Contractor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
License Class License No. 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
WORKEWS COMPENSATION 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 requestwhen
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 workfor which
this permit is issued. www.leginfo.ca.gov/calaw.html.
Policy# 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 o 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 an 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 with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# Expires operty for inspection purposes,
(This section need not to be completed is the permit is for one-hundred (
dollars($100)or less Date
IIgQt1!TY OW OWR AUTHORIZED AGENT
o I certify that in the performance of the work for which this permit is issued, _JEFF
I shall not employ any persons in any manner 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 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 specified an the Hazardous Materials Information Guide?
WARNING: AILLIFIETO SECURE WORKER'S COMPENSATION COVERAGE 15 o Yes o No
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 TOONE HUNDRED THOUSAND DOLLARS($100,000),IN
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FO occupant require a permit for the construction or modification from South
R 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 o Yes o No
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) a Yes a No
OWNER BUILDER DECLARATIONS I have mad 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 underthe State of
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 7031.5
Business and Professions Code).Any city or county that requires a permitto ciYes o No Date
construct,alter,Improve,demolish or repair any structure,prior to its PROPERTY OWNER OR AUTHORIZED AGENT
issuance,also requires the applicant for the permitto file a signed statement
that he or she is licensed pursuant to the provisions of the Contractor's State EPA RENOVATION,REPAIR AND PAINTING(RRP1
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)orthat 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 Applicant for a permit subjects the applicant to a civil penalty of not more
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 sale employees.For more information about EPA!s Renovation Program visit:
compensation,will do( )all of or I )portion of the work,and the structure is www.epa.gayllead 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 for the purpose of sale. - o 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 FAIR rule please fill out the RRP
Acknowledgement.
CERTIFICATE OF OCCUPANCY TENANT DI
SCLOSURE FORM
'" ' Menifee
�P;`
AZb'
DATE (2- ft PERMITNUMBER Qw 0
)t Manifee
ADDRESS 0 1-2 A r2 L.: Ae M Lo r- r Bulk�n'Lgy I, Safety Dept
BUSINESS NAME (�kogA e-t'G DEC 13 2016
INTENDED BUSINESS USE r-%
Hec eived
IS THIS A NEW BUSINESS IN THE CITY OF MENIFEE? NO (CIRCLE ONE)
ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? YES (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? YES (CIRCLE ONE)
SQUARE FOOTAGE (I 6D*a
NUMBER OF EMPLOYEES
NUMBER AND LOCATION OF RESTROOM FACILITIES 'L)A t,�-, 46
LIST ANY TOXIC CHEMICALS, FLAMMABLE/COMBUSTIBLE LIQUIDS OR GASES USED OR STORED WITH
MSDS SHEETS AND QUANTITIES OF EACH BELOW OR ON A SEPARATE ATTACHED SHEET(S):
— ��I A
0 ARE YOU MAKING ANY IMPROVEMENT TO THE SUITE OR BUILDING OTHER THAN PAINTING,
PAPERING, FLOOR COVERING, MOVABLE CASES,SHELVING OR PARTITIONS NOT OVER 5' 9" HIGH?
YES (�) (CIRCLE ONE)
APPLICANT SHALL OBTAIN ALL REQUIRED CLEARANCES AND/OR APPROVALS FROM THE
APPROPRIATE WATER DISTRICT AND FIRE DEPARTMENT PRIOR TO ISSUANCE OF ANY
BUILDING PERMITS
SIGNATURE DATE
PRINTNAME
OWNER / CONTRACTOR / ARCHITECT / ENGINEER (CIRCLE ONE)
OCCUPANCY GRP TYPE OF CONST STAFF INITIALS
3cp-ok L�
City of Menifee Building& Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityofmenifee.us Inspection Request Line 951-246-6213
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