PMT16-04122 City of Menifee Permit No.. PMT16-04122
29714 HAUN RD. Type: Residential Mechanical
<A—CCEU� MENIFEE,CA 92586
nsd— MENIFEE Date Issued: 12115/2016
P E R M I T
Site Address: 27921 LEXINGTON CT, MENIFEE, CA Parcel Number. 335-091-014
92586 Construction Cost: $13,447.00
Existing Use: Proposed Use:
Description of HVAC REPLACEMENT 3-TON PACKAGE UNIT AND ALL DUCT WORK
Work:
Owner Contractor
KEN BUKOWSKI RKM HEATING AND AIR CONDITIONING
27921 LEXINGTON COURT 11801 PIERCE ST#200
MENIFEE, CA 92586 RIVERSIDE, CA 92505
Applicant Phone:9516569970
BETH KRENING License Number: 936726
RKM HEATING AND AIR CONDITIONING
11801 PIERCE ST#200
RIVERSIDE, CA 92505
Fee Description Qtv Amount
Forced-Air or Gravity-Type Furnace or Burner 1 149.00
Air Handling/Condensing Units SFR 1 133.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Mechanical 1 14.10
$324.10
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 bulliding 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_Bldg_Pemit Template.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 perjurythat 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 C17d se is in full force and effect. the following reason:
License Class LicenseAIo. By my signature below I acknowledge that except for my personal residence
Expires :!!�//l in which I must have resided for at least one year prior to completion of
Signature. I�Iylll
04 9,j�
�11 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
ci 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
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/�law.htmi.
Policy# Date
ci 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 ci By my signature below I certify to each of the following:I am the property
this permi it is is 7 ed.My worker's compensation insurance carrier and policy owner or authorized to act on the property owner's behalf.I have read this
number a A 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#,2!, 41 Expires 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
o I certify that in the performance of the work for which this permit Is issued,
Ishallnotemplo any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
workees 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 fbr"ith comply)up those provisions, Will the applicant or future building occupant handle hazardous material or a
0(
=;51t
Applicamt_ V!,2Z / Date C:��l �Z mixture containing a hazardous material equal to or greater that the
A2&1��4 amounts specified an the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S C04PENSATION COVERAGE IS Dyes ONO
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 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 perrormance 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
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 nextto the applicable item(s)(Section 7031.5 Dyes 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 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(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 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
u 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 )all of or I )portion of the work,and the structure is www.epa.gov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-SOD-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. n No EPA Lead-Safe Certified Firm is required for this project because:
u 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.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION
"Menifee
DATE PERMIT/PLAN CHECK NUMBEqtMt OIJJQQI�
TYPE: EI COMMERCIAL 2RESIDENTIAL E]MULTI-FAMILY E]MOBILEHOME []POOL/SPA [-]SIGN
SUBTYPE: []ADDITION E]ALTERATION [-]DEMOLITION F]ELECTRICAL [-]MECHANICAL
[]NEW []PLUMBING F�RE-ROOF-NUM13ER OF SQUARES
DESCRIPTION OF WORK f kw��
�60,) �-
PROJECT ADDRESS 1eXah_,7),Aj 61' 1%U1,1Cee I-A Z,17—
City of Menlfee
ASSESSOR'S PARCEL NUMBER lywI- 0!31 !01 U LOT TRACT Building & Safety Dept.
PROPERTY OWNER'S NAME nFc I s 2nis
ADDRESS
PHONE EMAIL o Heceived
APPLICANT NAME
14E"t6
ADDRESS 6,� /�V
:��t 14
PHONE 21L EMAIL
CONTRACTOR'S NAME OWNERBUILDER? [_IYES2U�O
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ 0 /3 SO FT L SO FT
APPLICANT'S SIGNATURE DATE
DEPARTMENT DISTRIBUTION 6SINE_S�LFCEi�_E��i�EE�
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP X
INVOICE PAID AMOUNT
AMOU T ��qLA-10 I - CASH -CHECK# 0 CREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT -
I I -_ CASH 0 CHECK# CREDITCARD VISA/MC
[OWNER 13UILDER VERIFIED OYES 0 NO DL NUMBER NOTARIZED LETTER 0 YES 0 NO
City of Menifee Building&Safety Department 29714 Haun Rd. Menifee, CA 92586 951-672-6777
www.cityofmenifee.us Inspection Request Line 951-246-5213
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