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PMT17-00775 City of Menifee Permit No.: PMT17-00775 29714 HAUN RD. 'ACCELA1 MENIFEE,CA 92586 Type: Commercial Electrical MENIFEE Date Issued: 03/27/2017 PERMIT Site Address: 30261 ANTELOPE RD, MENIFEE, CA Parcel Number: 92584 Construction Cost: $800.00 Existing Use: Proposed Use: Description of INSTALL 1200 AMP TEMP POWER POLE FOR TEMP SALES OFFICE FOR LA FITNESS Work: Owner Contractor FITNESS INTERNATIONAL LLC ACTION POWER INC 3161 MICHAELSON DR#200 20532 CRESCENT BAY DRIVE IRVINE,CA 92612 STE. 106 Applicant Phone:9497098006 STEPHANIE CARLSON License Number:947176 ACTION POWER INC 20532 CRESCENT BAY DRIVE STE. 106 LAKE FOREST, CA 92630 Fee Description Oty Amount f$1 Services, Switchboards, Control Centers&Panels 1 183.00 Building Permit Issuance 1 27.00 Additional Plan Review Building 148 148.37 GREEN FEE 1 1.00 General Plan Maintenance Fee-Electrical 1 9.15 $368.52 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_Permk_Template.rpt Page 1 of 1 CITY OF MENIFEE LICENSED DECLARATION property who builds or Improves thereon,and who contracts for the projects with a licensed contractors)pursuant to the Contractors State License Law). I hereby affirm under penalty of perjury that I am under provisions of Chapter9(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 Coder and my license is in full force and effect. the following reason: License Class L- 6 License o. 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 WORKER'S COMPENSATION DECLARATION have built as an owner-builder if it has not been constructed in its entirety by ❑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 www,leginfo.ca.gov/calaw.htmi. this permit Is issued. Policy# Date PROPERTY OWNER OR AUTHORIZED AGENT 1 have and will maintain workers compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which ❑By my signature below I certify to each of the following:I am the property this permit is issued.My workers compensation insurance carrier and policy owner or authorized to act on the property owners behalf.I have read this number are: application and the information I have provided Is correct.I agree to comply with all applicable city and county ordinances and state laws relating to Carrier building construction.I authorize representatives of this city or county to Policy# QcX1 �0 Expires Li }- 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 .�fi� ❑I certify that in the performance of the work for which this permit is issued, /1 /aE I shall not employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE# lJ �V � workers compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION subjectto thew frkers compensation provisions of Section 3700 of the tabor Code,I shall fo kv'h comply with those provisions. Will the applicant or future building occupant handle hazardous material or a Date .� 7"7 mixture containing a hazardous material equal to or greater that the Applicant amounts specified on the Hazardous Materials Information Guide? WARN :FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes kf�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 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 SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguidelines CONSTRUCTION LENDING AGENCY ❑Yes &No 1 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) ❑Yes k6Ro 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 California Health&Safety Code,Section 25505 and 25534 concerning Contractors License Law for the reason(s)indicated below by the hazardous material reporting. checkmark(s)I have placed next to the applicable Items)(Section 7031.5 loes ❑N 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 PRE WNER 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 Contractors State EPA RENOVATION,REPAIR AND PAINTING IRRPI 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 Applicantfor 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 orthrough their ❑I,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 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 1-800-424-LEAD(5323). Code;The Contractors State License Law does not apply to an owner of 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. ❑No EPA Lead-Safe Certified Firm is required for this project because: ❑I,as owner of the property am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and Professions Code:The Contractors 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. SAFETYBUILDING & PERCHECK MIT/PLAN APPLICATION •f *75 DATE 31 )q PERMIT/PLAN CHECK NUMBER IT D7 TYPE: D✓ COMMERCIAL RESIDENTIAL D MULTI-FAMILY D MOBILE HOME POOLISPA SIGN SUBTYPE: DADDITION ALTERATION DEMOLITION D✓ ELECTRICAL D MECHANICAL ❑NEW [—]PLUMBING DRE-ROOF-NUMBER OF SQUARES DESCRIPTION OF WORK 200amp Temp Power Pole PROJECTADDRESS 5;ozc�! -/JWmz0^0 ASSESSOR'S PARCEL NUMBER 36Lf. olo • Cle- LOT TRACT PROPERTY OWNER'S NAME LA Fitness ADDRESS 3161 Michaelson Drive,Suite 200 Irvine CA 92612 PHONE EMAIL APPLICANT NAME Stephanie Carlson ADDRESS 20532 Crescent Bay Drive,Suite 106 Lake Forest,CA 92630 PHONE (949)709-8006 EMAIL stephanie@actionpowerine.com CONTRACTOR'S NAME Dan Carlson OWNER BUILDER? DYESD✓NO BUSINESS NAME Action Power, Inc ADDRESS 20532 Crescent Bay Drive,Suite 106 PHONE (949)709-8006 EMAIL stephanie@actionpowerinc.com CONTRACTOR'S STATE UC NUMBER 947176 LICENSE CLASSIFICATION C10 VALUATION SQ FT L SQ FT APPLICANT'S SIGNATURE DATE DEPARTMENT DISTRIBUTIONCITY OF ME FEE BUSINESS CENSE NUMBER BUILDING PLANNING ENGINEERING FIRE GREEN SMIP INVOICE PAIDAMOUNT AMOUNT OCASH % EDITC CHECKH OCRARD VISAIMC PLAN CHECK FEES PAIDAMOUNT O CASH '`-CHECK N '7)CREDR CARD VISA/MC OWNER BUILDER VERIFIED O YES 0 NO DLNUMBER NOTARIZED LETTER YES " NO City of Adenifee Buiidinq&Safety Department 297.14 Haug Rd. Nienifee, CA 92586 951-G72 6777 _m wrvw.cityofinenifee.us b75pectian Request One 95i-246-5213 Office Copy � I 1 U LID e s lC p C rn CD D W C7 N n L `V �. o a Trn CDCD (D c " � ee D 0 z9 n - m • p O m m O N /�D Cn K = m O O O D y 2 n 0 z 3 m _! m O y O 3 Z We S X .' -mc--Ow�'�� LA FITNESS MENI FEE ''